Health Committee - Minutes of EvidenceHC 171

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Oral Evidence

Taken before the Health Committee

on Tuesday 25 June 2013

Members present:

Mr Stephen Dorrell (Chair)

Rosie Cooper

Andrew George

Barbara Keeley

Charlotte Leslie

Grahame M. Morris

Andrew Percy

Mr Virendra Sharma

David Tredinnick

Valerie Vaz

Dr Sarah Wollaston


Examination of Witnesses

Witnesses: Rt Hon Earl Howe, Parliamentary Under-Secretary of State for Quality, Department of Health, Professor Sir Bruce Keogh KBE, NHS Medical Director, Dame Barbara Hakin DBE, NHS Chief Operating Officer and Deputy Chief Executive, and Professor Keith Willett, National Director for Acute Episodes of Care, NHS England, gave evidence.

Q214Chair: We are running a little late and apologise for keeping you waiting. Minister and colleagues, you are very welcome to the Committee this morning. Could I ask you to begin by briefly introducing yourselves? Minister, I think we probably know each other.

Earl Howe: Thank you, Chairman. I am Lord Howe, and I am one of the Ministers in the Department of Health.

Dame Barbara Hakin: I am Barbara Hakin, and since April I have taken over as the interim Chief Operating Officer for NHS England.

Sir Bruce Keogh: Good morning. My name is Bruce Keogh. I am the Medical Director for NHS England.

Professor Willett: I am Keith Willett, National Director for Acute Episodes of Care in NHS England.

Q215Chair: You are here to give evidence in our inquiry on urgent and emergency care, particularly in the context of the review that we know Sir Bruce Keogh is leading. You have published 12 priorities. To suggest that there are 12 priorities is in itself a dangerous thing to do. Do you think that is at risk of being too blunt a message?

To couple that with a second question, you characterise them as priorities for commissioners in the year 2014-15. Given the press coverage of urgent and emergency care a couple of weeks ago, to be talking about priorities for 2014-15 seems quite a long way away. It is both a very broad range of priorities and quite a long way away.

Earl Howe: The broad range of priorities reflects our view that there is no single cause of the recent pressures on A and E. The causes were many and various. It is difficult to find a word other than "priorities". It makes it sound as though one is targeting a rather broad front, which we have to do.

The reason for looking at 2014-15 is that we are clear we have to address the problems in the short term-perhaps we can come on to how we are doing that-but this is very much a medium to long-term issue. If one looks at the growth in pressure on A and E over the last few years, it is evident that this is not just a short-term problem. One has to look at how the system as a whole works.

You need to look at the way in which primary care integrates with ambulance services; the way that that integrates with acute care; the way that acute care integrates with social care; and again back to primary care. While looking at 2014-15 may seem like a long way away, we need that sort of run-up to have the kinds of conversations that are necessary to make sure that we have a system that is configured properly.

Q216Chair: In fact, I correct myself. I said 2014-15, but you are looking at 2015-16, are you not, which is very nearly two years away?

Professor Willett: I am sorry if we have not made it very clear. They are not priorities. We put out system design objectives. They were not what we were saying had to be done; they were 12 objectives that we put out there to build in public and to be criticised, discussed, commented on and added to.

This is a medium to longer-term review to look at how we restructure urgent and emergency care from the advice that a patient may get right through to their hospital care. This is a longer-term review. These objectives are, from the patient’s perspective, the system that the steering group, which has started the first phase of the objective, has suggested is the way we should go. That is what we have put out for an eight-week period of engagement, and we are looking for the public, members of NHS staff, experts and people with experience in the field to add to those in order to develop them.

Q217Chair: To put another pebble in the pool, are you saying that this is medium-term planning and everybody has to do that, but this is not addressing the service pressures that filled the newspapers two or three weeks ago? That is a different stream of work, and the work that Sir Bruce Keogh is doing is not intended to address those service pressures.

Professor Willett: That is, in part, correct. In terms of the immediate response to pressures-Barbara may wish to speak to this-we have supported urgent care boards in each of the local areas with patient, CCG and local authority involvement to address the issues in the short term. This is a medium to long-term review, which will take over from that.

For the coming winter-clearly, we would anticipate similar pressures-we need to optimise the system we have, but we recognise that at the moment it is unsustainable and we will need to make more substantial redesign. We do not need to do a top-down imposition of that, because the issues have been very different in different parts of the country. We are looking to set out objectives from a patient perspective that people can then build on locally to design their services, but we want to do that in public-not as a central diktat.

Sir Bruce Keogh: We are trying to do this in a slightly different way from usual. One thing everybody is agreed on is that the current position of urgent and emergency care is unsustainable and we need to do something. We need to do some things in the short term to address the immediate issues, and then we need to take a longer, more considered and deliberate view about how we address the future.

There are a number of reasons for that. First, there are clear issues, with which this Committee is well familiar. The demands on urgent and emergency care are growing, not necessarily so much in volume but in particular in the nature of the patients who are being presented, so the number of patients who are admitted to hospital who present is going up. We are seeing fragmentation between different parts of the system, which, if it were resolved, could alleviate the problem to some extent.

Furthermore, the practice of medicine has changed. When A and Es were set up a few decades ago, or DGHs came into their own, people could walk in with a problem and most DGHs were capable of dealing with it. But the inexorable advance of medical science means that now there are many common conditions that cannot be treated in an average DGH. A typical example would be a serious heart attack. That requires a degree of expertise and technology, which means that the treatment of it needs to be focused-I hate to use the word "centralised"-in specific centres, and similarly with strokes.

We have demographic and medical practice changes, and that demands that we reconsider things. We have put together an evidence pack that we think illustrates the nature of changing practice and different demands. That is the evidence that we have been able to accrue. It has 300 references, some of them scientific, some based on policy documents and others. We want that out in the open and for people to add to it, subtract from it, to say that these data are out of date and these data could be improved. It is only when everybody understands the case for change, or indeed whether there is a case for change, that we can have an informed debate. We are trying to set the platform for an informed debate about how we organise, configure and deliver services in the longer term.

Dame Barbara Hakin: This medium to longer-term piece of work needs to go on concurrently with the work that we are doing across the system to try to support our overstretched services at the moment. As you rightly point out, we had a prolonged dip in the times that patients waited for treatment in A and E departments. We always have pressure on urgent care over the winter, but generally the majority of our hospital services are able to get back to running smoothly round about March/April time.

This year we had a longer dip, which is almost like a barometer of the system, as Bruce has so rightly pointed out, for a variety of reasons, and there are demands on the urgent care services in general across the board, not just in accident and emergency departments. There are more elderly patients with longer-term care needs. When the system is not running efficiently and smoothly, we tend to see it in the time that vulnerable or ill patients are waiting to be admitted to A and E.

The vast majority of patients are discharged from A and E services whether they are in type 1 large acute services or in the walk-in centres. Those patients tend to be treated promptly. They are often discharged quite quickly. It is not those patients who wait more than four hours. Looking at the relatively small number of patients out of 100 who arrive and are admitted, if a hospital A and E service is not meeting the standard, which we consider gives the patients their constitutional rights to be admitted in that time, you are starting to talk about patients who are unwell and have been deemed to need admission to hospital having to wait in the accident and emergency department because a bed is not available for them.

We have started to look at how we can support the service particularly for next winter. We are now in a period when the number is going down, but we do need to support the service for next winter. I wrote to the area team directors of NHS England in April, shortly after I arrived, to ask them to bring together all the key players across the health system and support the CCGs, who are the commissioners of A and E, working with their local hospitals, in order to create a plan that would help us through the next few months, and certainly next winter. We know that, where the health economy works and everyone comes together to decide on the holistic care of patients, those are the places that provide the most efficient services.

We are working closely at the centre with Monitor and the Trust Development Authority, which are the organisations that oversee the hospitals, but we need to see local action. Therefore, the three organisations are supporting CCGs, in particular locally, to work across the system to convene urgent care boards-in lots of places those boards were already in existence-to support everybody to be in a better place next winter.

Chair: We are coming on to urgent care boards. Virendra wants to come in quickly on this.

Q218Mr Sharma: Briefly, if I understood rightly, these are not priorities but objectives. Professor Willett, you said that you were looking forward to people’s comments on them.

Professor Willett: Absolutely.

Q219Mr Sharma: Are you saying that it is a mini-consultation?

Professor Willett: It is an engagement, and we are going to build this.

Q220Mr Sharma: There are two ways of doing it. One is to send it out to the professionals and opinion-formers to seek their views on it, or are you saying that people, if they happen to read it, can respond to it?

Professor Willett: Let me clarify. It is not a formal consultation because we are not saying, "This is what we are going to do. What do you think?" This is us saying, "We’ve got this far with it with phase 1. These are the ideas that people have come up with; these are some of the objectives we have drawn from the evidence base that we are also putting out there."

We recognise that the issues of urgent and emergency care cover the full breadth of the pathway for the patient. If we are going to deal with them, we need to draw on the expertise and experience of all the staff in the NHS and the patient experience. You are exactly right: this is out there to engage and help us. We will bring it all back in together and look at it again, and then we will put it out again. That is the intention. So, yes, I want the public to contribute, and the website is set up to do that.

Q221Mr Sharma: I am not yet clear whether you are sending out the message to the local professionals that they have the opportunity to comment on it.

Professor Willett: Yes.

Q222Mr Sharma: You are publicly saying it.

Professor Willett: It is being put out publicly; it is on the NHS England website. In terms of the locality, there is an option that as people contribute they can also put in the first part of their postcode. Not only will we be able to have a national view and contributions, but we will be able to distil that down to give that in a distilled form to local areas, which clearly ultimately will be responsible for commissioning the integrated service.

Q223Valerie Vaz: Forgive me, but I thought I heard you all saying, "Crisis? What crisis?" You need to answer the Chairman’s first question: what are your priorities for emergency services, given what is going on now? What are your priorities now to sort out the mess?

Dame Barbara Hakin: We are very clear that this is a local issue and that, locally, the CCGs with their providers need to look at what happens to patients before they arrive in hospital. So there is a broad range of things that can be done locally.

Q224Valerie Vaz: What are your priorities? Just give us your priorities. You must have had a discussion in the Department of Health as to what is happening on the ground. It is not about writing to people. What are you doing now to sort it out?

Earl Howe: Three things. There is extra money.

Q225Valerie Vaz: Extra money: how much, and where from?

Earl Howe: We are looking at the tariff for emergency care. As you know, the marginal rate tariff introduced under the last Government applies when certain thresholds have been exceeded in terms of admissions to hospital. The marginal rate tariff is 30%. In theory, the other 70% is there to enable commissioners and providers to work together to look at ways of reducing demand. That has not worked very well. We need to mobilise that 70% of the tariff that commissioners have to get those conversations going, hence the urgent care boards, which have been referred to.

In the immediate term, we are looking at how we can prevent another winter like the last one from happening again. Then there is the medium-term work, which Sir Bruce has referred to, looking at the root causes of all of this. The Foundation Trust Network has come up with quite a long list of the root causes, hence the rather long list of objectives that have been defined. We broadly agree with what the FTN said.

As I alluded to earlier, in the very long term we have to look at changing models of care to respond to changing patterns of illness and what we see in local populations. There is a short, medium and longer-term agenda, and perhaps we can help you by refining that a bit more.

Q226Valerie Vaz: You mentioned extra money: where from, and how much?

Earl Howe: It depends on the area. I look to my colleagues to come up with precise sums, but it does depend on the area you are in. Clearly, budgets will have been used in different ways.

Q227Chair: It is to do with the 70%, is it not? When you say "more money," you are focused on how the 70% is being used. Is it being used for emergency care or for something else?

Earl Howe: To be clear, it is releasing money that is already in the system.

Chair: Exactly.

Q228Valerie Vaz: You mentioned the short term and long term. I was asking for a response to the Chairman’s question. What are the priorities for now? You answered that there were three, but you are giving me short term and long term, are you?

Earl Howe: The priorities for now-

Q229Andrew George: It is only one that you are doing now, and that is inspecting whether the 70% of the commissioning money is being deployed on the front line effectively. The other two objectives you mentioned were medium and long term.

Earl Howe: Okay, but I think the short-term ones for now are important nevertheless. I should also mention that there was extra money put into the system over the last winter. That was £330 million.

Q230Mr Sharma: What are the short-term ones?

Chair: Can we have one at a time?

Earl Howe: As I said, the short-term priority has to be to make sure the system is configured so that we do not get similar unacceptable pressures in the system next winter, hence we are looking at how we can mobilise that 70% of the tariff much more effectively. The urgent care boards have been formed in part to do that, but that is not their sole function. Their function is a broader one: it is to get the engagement of all the local players, including social care, to see how people can work better together.

Dame Barbara Hakin: We have been very strong that this is a devolved system and that all the money has gone out to front-line organisations, CCGs led by local clinicians, and the solutions will be local. This is about how, locally, elderly patients are better supported in their own homes, either with medical or social care, so that they do not need to be urgently admitted when they are ill, if they can be and want to be treated at home. This is about local hospitals being able to discharge people quickly, because often the problems are about difficulties with beds; it is about making sure that all the services are in place for individuals so that when they are ready to be discharged they can be. The solutions to this will be found by people working together in individual places and understanding what their priorities are.

One of the other ways in which we are trying to help them is by sharing best practice. We are doing that by development and learning events that we are holding, as well as with documents. In lots of places there are pockets of good practice. If they were spread and every local community did that, we would start to see much less pressure on those services.

Chair: Can I say that we are half an hour into this now and we haven’t made much progress yet?

Rosie Cooper: I am losing the will to live.

Chair: Can we move to David Tredinnick, and can I appeal for reasonably focused, brief responses to the questions, please?

Q231David Tredinnick: Minister, I want to probe you about the current structure. How many urgent care boards are there? Who is responsible for establishing their size and overseeing their composition-the way that they have been put together-and assessing what has happened, assuming you have decided their size, and that it works? How many boards are there?

Dame Barbara Hakin: They are absolutely local. We say that there should be one for every major provider.

Q232David Tredinnick: Is there?

Dame Barbara Hakin: They are established now, yes.

Q233David Tredinnick: How many are there? Give me a figure.

Dame Barbara Hakin: We have absolutely left this to local discretion.

Rosie Cooper: So what have you come for? Forgive me, if everything is going to be left to local discretion and you do not know the answer to the numbers, I just do not understand why you are here if you cannot answer these questions.

Q234David Tredinnick: May I pursue my line of questioning? Can you give me the approximate number of urgent care boards that we now have?

Dame Barbara Hakin: There are round about 150 to map on to the acute providers.

Q235David Tredinnick: Is it the local providers who establish their size? Is it a very flexible system? Do we have some boards that are enormous and some that are very small, possibly under-resourced?

Dame Barbara Hakin: Yes.

Q236David Tredinnick: Under-resourced?

Dame Barbara Hakin: Who needs to be on the urgent care board is left to local discretion, but we were clear that one of the things the urgent care board should do is to identify the use of the 70%. For that, we said that the chief executives of the local commissioners, which is the CCG, the area team and all providers-the ambulance trust, mental health trust and acute trust-should sign off the use of that money. That is the minimum group of people who would be there alongside the local authority, because we said there had to be local authority input. Where it is appropriate to have clinicians, they will have many clinicians on them, because the idea of the board is to bring together local experts to determine what they need to do.

Q237David Tredinnick: I am getting the impression that, at the moment, it is not very clear within the Department how many boards there are and whether they are large or small. It appears to me that part of your task is to find out what you have got.

Dame Barbara Hakin: We are aware; we have the details of them.

Q238Chair: Could you share them with us?

Dame Barbara Hakin: They are varied as to what people do. We have one for each provider. We have had all the plans that have come in from each pathway-

Q239David Tredinnick: How many of these are large urgent care boards and how many are small? When the Conservative Government was elected in 1979, the Department of Health had absolutely no idea how many buildings it owned. I am reminded of that period. One of the first things the incoming Government had to do was establish what the Department of Health owned. I am trying to find out the scale of your operation as far as urgent care boards are concerned-and to be helpful.

Dame Barbara Hakin: I just feel that there is a slight misconception that an urgent care board is part of a governance structure, whereas it is a group of people coming together from the locality-the senior executives and senior clinicians-to work out the best way to do things. It is a consensus-building group. Maybe different people attend them at different times, depending on what they are looking at. It is not part of a governance structure where we would keep a formal record of who was on it and how it was constituted.

Q240David Tredinnick: Okay; fine. We are short of time. I am going to develop this a bit more and then leave it to the Chair. What time frame is attached to the work of the urgent care boards? Are they going to become a permanent feature of local commissioning and management structures?

Dame Barbara Hakin: I repeat that I do not see them as a feature of a management structure.

Q241Chair: Forgive me and I apologise, Dame Barbara, but in your first answer, in response to the short-term pressures, you volunteered urgent care boards. Now you tell us they are not an effective part of the management structure of the health service. Which is right?

Dame Barbara Hakin: They are not part of the governance structure.

Q242Valerie Vaz: What does that mean? Secret structures?

Dame Barbara Hakin: I believe they are very effective in bringing people together. We have had lots of feedback. For the first time, the relevant social care players-the GPs from the CCGs and the clinicians from the hospitals-are coming together to talk about their issues and problems. That is the point of these boards. So, yes, they are an effective part of the structures, but they do not have a decision-making authority.

Chair: I am sorry but I have 11 colleagues now, all of whom want to come in. Virendra is closest to me.

Q243Mr Sharma: Are they temporary and not a permanent part of the structure?

Dame Barbara Hakin: I can see no reason why they would not remain permanent, simply because why would you not bring together the people who are responsible for care?

Rosie Cooper: That is what we have asked you already.

Mr Sharma: We are asking you.

Chair: Order, order. Could we have one at a time?

Q244Mr Sharma: I am just asking you: is it a temporary or permanent feature of the system? You said it can be permanent, but what are your guidelines for the system that it should be?

Dame Barbara Hakin: We have simply asked them to set them up. We have not, as yet, determined whether we would say they could cease, but it seems to me to be a very good thing to do for patients. I hope that they work really well, and why would we not continue with them?

Chair: Could we have brief questions on urgent care boards? Then we need to move on.

Q245Charlotte Leslie: I think we are struggling with the formality and the set-up of these things. First, how much public money would you expect an individual urgent care board to take up in its set-up?

Dame Barbara Hakin: None. It is a meeting of individuals, all coming as representatives of their individual organisations.

Q246Charlotte Leslie: So there would be no public money in terms of hiring a venue or any logo. You can guarantee that no public money would be used in the setting-up of urgent care boards.

Dame Barbara Hakin: Inevitably, when there is a meeting, there will be the people who service the meetings. The people who attend the meetings will be public servants. Their salaries are paid by the public, and it is taking their time. But these are not structures that are designed to have teams of people working for them. It is a meeting of people from the individual organisations.

Q247Charlotte Leslie: Secondly, would any decisions taken or conversations had in those meetings be subject to FOI in the normal way?

Dame Barbara Hakin: If there was an FOI for an urgent care board, I cannot see that there would be any reason to withhold the information. It would be subject to normal FOI rules.

Q248Dr Wollaston: Presumably, there is always a cost, because if a surgeon has to cancel their list to attend a meeting, that time has to be replaced. Unless they are meeting voluntarily out of hours, there is a cost, I would suggest. However, this is my main question. We know that system reconfiguration is extraordinarily difficult. If an urgent care board decides there is clearly a problem in the way that the system is operating locally but it has no power, is it going to be a toothless jelly? Is it going to have any power to force through changes where everyone can agree that that is the best way forward?

Dame Barbara Hakin: For the most part, we expect urgent care boards to be looking at the day-to-day changes they need to make in terms of patient management. How can they work better across primary and social care, and so on? If in a meeting of the urgent care board there is a decision that something major needs to happen, that will have to go back through the formal channels of the CCGs. We also have health and wellbeing boards. That is really the formal place locally where, if there was any suggestion of major changes to services, that decision would be taken.

Q249Dr Wollaston: So we are talking about minor tweaking within systems in departments in the short term.

Dame Barbara Hakin: Yes. I would not like to use the term "minor tweaking," but the urgent care board is there to look at changes in day-to-day operational issues. How can people work better together to support patients on a day-to-day basis? That is their main aim.

Q250Dr Wollaston: It is that rather than reconfiguration.

Dame Barbara Hakin: Absolutely.

Q251Andrew Percy: Am I right in thinking that this is simply about getting all the players involved in urgent and emergency care round the table, and, if a locality finds it is working and wishes to continue with that arrangement in the longer term, it will be able to?

Dame Barbara Hakin: Absolutely.

Q252Andrew Percy: It is as simple as that.

Dame Barbara Hakin: It is as simple as that.

Q253Andrew Percy: I am struggling to find out quite why people have difficulty with the concept of bringing people together. If a locality decides in the longer term that it does not wish to operate in that way, it will not have to have an urgent care board, but if one decides that it is working it will continue to have an urgent care board.

Professor Willett: With the new Health and Social Care Act we are in a much better position, in that just about all the elements of urgent and emergency care, whether we are talking about out-of-hours services, ambulance services, A and E services, or acute services within the hospital, now fall under the clinical commissioning groups. The urgent care boards are making sure that all of those come together with the areas adjacent to them, like the local authorities, so that in this new structure-which is new to everybody-they are talking. That is simply what it is doing.

We know that, if you walk through the patient pathway, there is not one single issue that will solve this problem. In one place it is one thing and in another place it is something completely different. It may be the way the out-of-hours service can relate to local general practices; it may be the way the ambulance service can access patient records in the house when visiting a patient; it may be the way the hospital A and E doctors can find out what medication the patient is on. All these are multiple elements in the system. With the urgent care boards, we are looking to make sure we are optimising the current configuration of services. That is what the urgent care boards will facilitate.

Q254David Tredinnick: To follow the remarks of my colleague Andrew Percy, looking at the structure and what has happened since the introduction of the Health and Social Care Act, when the chief executive of the NHS Confederation, Mike Farrar, came before the Committee, he told us that the Health and Social Care Act had removed system management roles that would previously have been in place to address the problems in emergency care. Are urgent care boards intended to fill this vacuum in management responsibility, which I believe, from what I have heard, emerged as a consequence of the Act?

Earl Howe: I would simply comment that performance management is rather different from what we have been talking about in terms of the function of the urgent care boards. Mike Farrar is right. Certain layers of administration in performance management have been removed, but, if you are going to find solutions to this, it is about local people agreeing on what the problems are, what needs to be done and taking ownership of those problems. He is correct in saying that we have lost something, but we have also gained something that I believe is potentially more powerful, because it is about people on the ground dealing with the problems as they see them, rather than somebody sitting in a PCT or SHA looking from on high and asking questions.

Q255David Tredinnick: Your understanding is that the new flexibility is going to deliver better results and that different communities can have more choice. The Government are committed to choice. This is part of the choice agenda, is it?

Earl Howe: Yes, all of that. The new flexibilities in the system are a very important aspect of them. Power is a zero sum game. If you remove a certain amount of power and influence from the centre, ipso facto you devolve it to local areas. The empowerment of local areas is a signal to them that they can be flexible in the way they respond to problems as they arise.

Q256Barbara Keeley: There is a point of clarification of earlier answers, particularly those of Lord Howe. You tended to say that this was a local issue. We have heard a lot about local problems. You also touched on preventing another winter. We have had a fair amount of evidence so far altogether, and we have already had a debate in the House on accident and emergency. My local hospital trust told me that they have 10% more ambulance arrivals every day; people are sicker; there are more 72-hour or longer stays and fewer shorter stays; there are 25% more triages into resuscitation; and a significant increase in risk and comorbidity. Patients need more attention and support.

As I read it, that is quite common across the piece, and yet you have left me with an impression that you think there are local issues, which tends to suggest that some places have issues that other areas do not. You have also left us with an impression that this is a winter problem. I understand that it is not and there have been problems in every quarter. Can you address those two things before we go any further? I would not want to leave that on the record if that is not correct.

Earl Howe: You are absolutely right to say that many, if not most, areas have certain features in common. You have listed several. The demands on the system from patients who have more complex conditions, particularly elderly patients, have been rising over the last few years in all areas. You are right that it is at all times of year, although winter is a time when the system is under the most pressure, quite obviously.

What I meant by variations between different areas is that, where there are blockages in the system, the reasons can differ from area to area. Professor Willett has already alluded to that. It might be that the hospital concerned is perhaps less good than others in seeing a flow of patients through and there is a certain amount of bed blocking. It might be that the local social services are not resourced as they should be; it might be that reablement services are not being commissioned as they should be. There is a variety of reasons why the problems have occurred, but many areas do have issues-the ones you have referred to-in common.

Q257Barbara Keeley: There is still a lack of clarity about structures. I have a question about the health and wellbeing boards and where they fit in in addressing this. You have talked about some big issues as being the things that need fixing if this situation is going to be improved. We have urgent care boards, CCGs and local area teams all tasked with dealing with this, and yet, Dame Barbara, you just referred to solutions that somehow had to come out of the health and wellbeing boards. Speaking for myself, this is not clear at all.

Professor Willett: That is a clinical perspective because your question was very clinically oriented. If you look at the figures, both nationally and for most areas, there has been a steady, almost identical rise in the number of people attending an A and E department, the number of ambulance calls and the number of people who are being admitted to hospital. That has climbed at a similar rate for each of those over the last 10 years despite all that has been done, so this is not something that has suddenly happened.

Q258Barbara Keeley: Earlier, reference was made to local issues. It is not a local issue; it is a national trend.

Professor Willett: It is a national trend.

Q259Barbara Keeley: It is a national trend that is having different manifestations, depending on the ability of local set-ups to deal with it.

Professor Willett: Absolutely. Our current position is that the system we have does not fit. That is because, as Sir Bruce has said, our patients have changed. They are now older and frailer; we have a higher dementia rate; we have a different perspective of patients arriving, but also the public has changed.

Q260Barbara Keeley: That ties in with what we thought was the evidence.

Let’s now move back to the question of structures because I think colleagues are really struggling with the structures. You have talked about something that sounds very flimsy and might be temporary or might last. There are other structures that need to feed into it. Dame Barbara, you said that urgent care boards cannot take the decisions; they have to go to health and wellbeing boards. Can anybody on the panel explain how all this fits together? We have even had questions about whether there will be cost involved in this.

Will the issues that you are talking about fix it? How could an urgent care board deal with an issue where a local authority was under-resourced, there was bed blocking and people were staying in hospital longer than they needed to? How could they do that? Where would the decision be taken that the problem is that x, y, z local authority has cut its budgets and there is bed blocking because of that? How do you fix that with the structure we have here?

Dame Barbara Hakin: I go back to the description of the urgent care board as local front-line staff coming together to identify what the problems are.

Q261Barbara Keeley: I understand the bit about identifying it, but how do they fix it?

Dame Barbara Hakin: An example might be patients with mental health problems.

Q262Barbara Keeley: No; take the problem I have given because Lord Howe referred to bed blocking where a local authority, not being resourced, has to cut back on eligibility and that is causing the problem. How is that going to be fixed by this set of structures?

Dame Barbara Hakin: The urgent care board might identify that as an issue. There may be ways, through people working together, talking to one another and seeing each other on the ground, to improve the way individual patients are managed across health and social care, but, if a decision is to be made about investment, the money for commissioning health care sits with CCGs, and the local authority money sits with the local authority. They come together in a much more formal way than an urgent care board in the health and wellbeing board with specific structures designed to bring together health and social care commissioners and local providers to make the broad decisions.

Q263Barbara Keeley: Indeed, but they do not have any power to increase the resources of the local authority. If the local authority has had a big budget cut from central Government and has reduced the money in social care, that board cannot fix it.

Dame Barbara Hakin: That is right. The local authority is represented on the board, so it can make decisions about the funding they have.

Q264Barbara Keeley: I understand how it works. We are tripped up now by a lack of resources in the local authority, and it sounds as if it is quite common. The health and wellbeing board cannot change that situation, or are we saying they can-that between these structures they can do something about that?

Earl Howe: In so many of these situations you are quite right that money is an issue, but it is not the only way of cracking a problem.

Q265Barbara Keeley: It is the only way of cracking a lack of social care problem, is it not?

Earl Howe: If you go round to many areas, and I have been to several, they are thinking very creatively about how they can take cost out of the system-for example, by joint commissioning of step-down care. Social services in Kent are working very closely with primary care providers.

Q266Barbara Keeley: That is fine, but take my local authority. It is making large cuts to social care this year and next because of the budget cuts from central Government. How do we fix a situation that might develop in my local area because of that? How do we deal with that? We do not have step up and step down; all that has gone. We have cut out an awful lot of things that we used to have locally. How do you create step up and step down, which is an excellent solution, when the budget is cut this year and next? If reports are to be believed, there is to be a further 10% cut in Communities and Local Government.

Earl Howe: As you can imagine, we are looking very carefully at this area in the context of the spending review, and tomorrow there will be news on that front. I know how constrained many local budgets are. Having said that, there are mechanisms in many areas for the pooling of resources, which can be deployed very effectively.

For example, in one area I visited, the pooling of resources meant that frail, elderly patients were looked after by a mixture of primary care clinicians and adult social care workers in a very creative way. That took cost out of the system, but it used money from both systems. If we can create those mechanisms, local people can then take advantage of them.

I do not wish to give you the impression that this is simple. We were aware at the beginning of the last spending review in 2010 how pressurised local authorities would be, which is why the Department allocated an extra £7.2 billion to local authorities specifically to shore up their resources. The King’s Fund at the time said that that would be enough, assuming a 3% efficiency in local authorities.

Q267Barbara Keeley: I understand. We have heard evidence from across emergency care of the benefits of working with a single commissioner. There is a point here about how that simplified commissioning can be achieved. We still have a situation where emergency care services extend across CCG boundaries. There might be different local authorities, health and wellbeing boards and urgent care boards. How can we get to that simplification, which seems to make things work where you can utilise it, when in certain areas it is going to be completely different?

Earl Howe: We are increasingly seeing CCGs working together, and effectively the net result is joint commissioning by CCGs.

Q268Barbara Keeley: But then you would have different health and wellbeing boards.

Earl Howe: That was always going to be part of the scene. I am not aware that the lack of congruence between local authority and CCG areas has caused a major issue in terms of decision making. If I am wrong about that, please correct me, but I am not aware of it.

Barbara Keeley: If I take my local area, Salford is next to Manchester City, which is next to Trafford. There are no longer any decision-making structures that span two or three of those. This is making structures of local government that go across 10 local authorities, but that is not a unit that would work with urgent care boards or CCGs. I think this is a very confused picture.

Q269Rosie Cooper: I have two questions to ask, but, before that, I want to tie up what I have heard so far this morning and follow on from Barbara’s question about all these differing organisations that will locally cross over and deliver care. I am willing the NHS to do really well, whether it is the Department of Health, NHS England or CCGs-to make the best of the hand that it has been dealt. Our lives depend on you guys enabling people on the front line to deliver.

I am still not clear what urgent care boards are about. Dame Barbara, you have described them in a contradictory fashion to me. I am hearing "temporary," "not part of the structure," "not decision making," "they are good," "people are delighted," "the first time clinicians got together"-that is a big surprise-and that you hope they work together in the long term. For someone like me, hope is not a long-term strategy. Hope is not a strategy, short or long term.

Is it any wonder that the public out there, looking at this description of what is attempting to deliver the health services on which their lives depend, are fearful that we are in a dreadful mess? It sounds like it is not us in the middle-it is not the Department of Health; it is not NHS England; it is not health and wellbeing boards; and it is not altogether CCGs. We are saying that locally we are all depending on somebody else. We all believe that somebody is waiting for somebody else to sort out the problem. If I was a member of the public listening to this, I would not have any confidence that anybody had a grip of where they are, what their priorities are and how they are going to deliver, whether it is winter or summer pressures or any other pressures. We have gone into a new era and all of this sounds very confused. That is not the question.

What assurance can the Minister give people that you can describe this in a fashion that people can understand?

Earl Howe: The simple point to be made is: look at the results. Already we are seeing the system performing to standard. That is a result of local clinicians and others in a local area getting together and making jolly sure that the slippage in performance is corrected in short order. We have had the system performing as a whole up to standard over the last six or seven weeks. That is what we all want to see continue. I see that as a result of a lot of effort by a lot of people talking to each other, not ducking responsibility but sharing it and making sure that they play their part in addressing the problems.

Q270Rosie Cooper: In that case, I suppose I would come back and ask what the standard is, but I will go on. The Royal College of GPs and the King’s Fund have said that attendances at type 1 emergency departments have flatlined over the last decade, but the College of Emergency Medicine reports year on year an increase of 250,000 attendances. How could we reconcile those competing claims? If we do not have the full information, how can the Committee hope even to begin to understand what is happening and how the NHS comes up with a solution?

Earl Howe: Attendances over the last three years have most certainly gone up by about 1 million. If one looks at a three-year period, that is an important point to factor in. It depends on what statistic you take about pressure on the system. That is the one we are working to. We believe it is reflective of reality, so I would leave you with that.

Dame Barbara Hakin: To answer that, the biggest rise in attendances has been outside type 1 A and E, and that is where we see some of the difference in numbers. There has been a rise over the decade for type 1 A and E, but the big rise has been in the total numbers of patients who attend A and E, including 2 and 3.

Q271Rosie Cooper: It is how we handle that.

Can I come to bed numbers in hospitals? Are they now too low to allow trusts to cope with fluctuations in demand while maintaining patient flow through the system? What work has been done to understand how many beds the NHS really needs to be able to cope with expected demand, or is it the case that we do not have the full information to understand exactly what we need in place? It is a continual problem for somebody like me who has been involved in the health service for years. Every winter we get the same thing over and over again.

Is it a continual problem? What is NHS England going to do about it? Or is it the case that we need more beds, which may not necessarily be acute beds, which moves over to Barbara’s point, but the system cannot afford it? My own hospital, Southport and Ormskirk, has to increase the number of beds every year to cope with that demand. To do it, it opens a ward, or does whatever, and that can potentially be a poor way to run a service. It is hard to recruit staff and you end up with agency nurses. It is all very push and shove, whereas this is the health service and we ought to be able to plan for this. Why can we not get it right?

Earl Howe: Perhaps the more appropriate measure to look at, if you are considering beds, is not bed numbers but bed occupancy rates. Of course, bed numbers matter. In my own area, south Bucks, where there has been a reconfiguration of A and E services, Wexham Park hospital was able to expand its bed numbers-two new extra wards and 28 beds-in response to increased demand. It can be done, and it is being done.

If you look at bed occupancy rates, the proportion of beds occupied in the NHS is broadly stable and has been for a number of years. It is around mid-80% on average. That is because, despite increasing numbers of patients being treated, we are seeing many more day cases. Almost 80% of inpatients were treated as day cases in the most recent year, so the system is becoming more efficient. The average length of stay in hospital, setting aside day cases, is coming down.

Clearly, each trust is responsible for ensuring that there are sufficient numbers of beds. Hospitals can and do upscale during the winter and downscale during the summer, as necessary. There is money in the system in capital budgets to enable hospitals to present a case for investment, so I would not want to fill you with gloom that the system is inflexible. It is not. There are systems to ensure that it can flex to meet demand.

Q272Rosie Cooper: You have just said that average bed occupancies are in the mid-80s.

Earl Howe: Over the year as a whole; that is what my figures say.

Q273Rosie Cooper: But the reality is that at times it is much higher.

Earl Howe: Yes; it is in the 90s.

Q274Rosie Cooper: Absolutely; so we cannot just not deal with that situation.

Earl Howe: No, indeed; we can’t not deal with that situation, and those figures of 90% during the winter demonstrate amply that the remedies we have been talking about are necessary.

Q275Rosie Cooper: Forgive me, but are there any signs that those 90% occupancy rates are now spreading more throughout the year?

Earl Howe: I will have to write to you about that. I do not have in front of me a chart showing a week-by-week profile, but we will gladly give you that.

Chair: Andrew George, Andrew Percy and Virendra all have points to make.

Andrew George: Or questions to ask.

Chair: Or even questions-evidence to seek.

Q276Andrew George: In your answer that bed occupancy levels were in the mid-80%, you were suggesting that that includes the acute sector wards that undertake routine elective work. Perhaps there is again a need to write to the Committee. Is it possible to have a little more detail on that figure? The anecdotal evidence, and certainly evidence we have received elsewhere, suggests that bed pressures have increased over time, particularly on those acute emergency receiving wards in hospitals, many of which are operating at red alert. The received wisdom or mantra about acute hospitals operating with fewer acute beds, on the basis that those hospitals should be operating in a manner that no longer accepts unnecessary admissions and discharges earlier, may be creating some of the pressure that the A and E services are unable to handle.

The first part of the question is: is it possible to have a little more sophisticated information about those that are elective wards and those that are emergency receiving wards?

Earl Howe: We will certainly do our best to supply you with that. It is clearly inefficient for a hospital to keep a whole mass of beds open when they are not needed, so in some instances it could be a case of a hospital not being responsive enough to the rise in demand. There are now quite sophisticated tools for them to predict the demand over the course of a year or even a week. I have seen those systems working. You are right. This could be part of the mix, and if we can enlighten you we will be happy to do so. I am not sure what figures NHS England have, but what they have we will give you.

Q277Andrew Percy: On bed numbers, there is an issue here. I attended and spoke in the Opposition day debate on this issue and was shocked that Andy Burnham’s introduction made no mention of anything that had happened in the run-up to 2010, which is perhaps not a surprise. But we did lose 50,000 beds and there was no mention of that in that debate.

I want to ask a similar question. I think most Members understand why beds have reduced and that hospitals are able to flex over the winter period, but in losing those beds over those 13 years was enough emphasis put on replacing some of them with proper intermediate services: step up, step down and all the rest of it? In part, that was Barbara’s point. Minister, do you have a view on whether or not losing 50,000 beds without a proper strategy around intermediate services is partly behind some of the problems we have seen in the system in the last year or two?

Earl Howe: I certainly would not set myself up as someone to defend Andy Burnham, but this trend has been going on for longer than 13 years, in fact. We have seen a steady decline in beds over more than 20 years.

Q278Andrew Percy: But we have had a demographic shift.

Earl Howe: We have. I suspect that we have reached the point where deep-rooted questions need to be asked about how much longer that trend can sensibly continue, given the pressures we all know about. I would not want to sit here and give you the impression that I think that trend was mistaken. It was almost certainly appropriate, because we have seen much better value for taxpayers’ money in delivering care in the NHS and much higher quality of care.

Patients do not want to stay in hospital for longer than they need to, and it is good that we are seeing length of stay coming down. But there does come a point where you have to reflect very carefully on whether bed numbers should come down even further, because in certain areas you could be taking a risk in doing that. I do not know whether colleagues want to add to that.

Professor Willett: Perhaps I may add to that from a clinical perspective. We said that medicine and our patients are changing. Now 65% of our acute admissions to hospital as emergencies are in the over-65 population, and they are occupying 70% of the acute beds. This patient group is very different from perhaps 20 years ago. Most of them will be living with one or more long-term conditions. Most people over 60 have two long-term conditions; most people over 70 have three; and most people over 80 have four. That is what the Scottish primary care dataset tells us. These are much more complex patients, often associated with frailty. The dementia rate now is 40%, and it is very challenging to give these individuals the care they deserve.

If we are able to intercept the decisions about getting patients into hospital earlier, we have talked about what general practitioners working with out-of-hours and the ambulance service can do, and how they can work with the community so that they can support the patient in the community. If that demented patient, who has been managing but now just needs a bit more care, can receive care in the community, that patient is not transferred to hospital. But I can assure you that, once that patient arrives in A and E because we have not got that bit right, it is impossible in three hours 59 minutes to identify all the patient’s needs and supply them with what they want, so that patient becomes a guaranteed admission.

Once they are in hospital, it is a strange environment for the patient. It may not have good information about the patient, and that often becomes quite a long stay. We can do things about that, as Earl Howe has indicated. We have reduced the number of acute beds by a third over the last 10 years, but the number of our emergency admissions has gone up by a third. I do not think we can say that we are completely efficient now in dealing with the new challenges in the NHS. There is a lot to be done.

We are now seeing new models where we are bringing senior medical staff, geriatricians in particular and emergency medicine staff, to the front door of the hospital. We are taking a bit longer, perhaps 12 or 24 hours, to assess these patients, bring in general practice and general practitioners, occupational health and physiotherapy, and move the patient back to an environment close to their home, which is supported. That is the new challenge.

Things like urgent care boards will start to be able to look at the best practice models, because that is not happening everywhere by any means. There are some real opportunities to change the service going forward. That is why we are doing the urgent care review because we want to seek those good examples and the evidence base out there. Medicine is changing so fast. A lot of that is not published and so cannot be in the evidence base from which we would traditionally work.

Q279Barbara Keeley: For clarification, we are getting confusing pictures again. You have just made a comment about shorter stays, but earlier I gave you a figure that I got from my local hospital. There has been a 13% increase in admissions of people staying longer than 72 hours. We hear about people being sicker and having to stay longer with a corresponding decrease in the number of people on short stays. We cannot have both. Hospitals and urgent care boards may be working to get to a situation where there are shorter stays, but the trend in patients seems to be working against that.

Professor Willett: I do not have intimate knowledge of your local hospital.

Q280Barbara Keeley: I do not think that is untypical.

Professor Willett: But we also have some really good examples of where those systems are being put in place and are working very effectively. That is the sort of thing we wish to share and spread around the NHS. I am not suggesting there is not an underlying issue around the number of beds.

Barbara Keeley: We need statistics. It is not my question; it is Andrew Percy’s question, but we cannot leave on the record that you are saying there are shorter stays, when the evidence seems to suggest that patients are sicker and there are longer stays. We must have some statistics on this; otherwise, it is just not clear. There may be a trend of working towards shorter stays, but, if the trend in sickness in patients means that is working against that, we should know which is which.

Chair: Could you write to us about that apparent conflict of evidence? I think Professor Willett’s last response pretty much answered where you were going.

Q281Dr Wollaston: It is not just about bed occupancy; it is about patients being in the wrong wards-for example, outliers receiving the wrong care-and it is about the knock-on effect on operations being cancelled because there are no surgical beds for patients to come into. How much will all of this feed into tariff reform? So much of this is about tariffs. Take the role that community hospitals could play in providing step-down care, but often it is an issue of tariff. You cannot split the tariff. How much of that is going to be fed in from urgent care boards and all these people to liaise with Monitor, who need to change the way tariffs are operated?

Professor Willett: The tariff is a very big subject, and we could cover tariff from the ambulance service right the way through. On the specific question you have just raised about the tariff in terms of moving patients into social care and into the community, we have started a piece of work, which I lead on, that looks at disaggregating the tariff a hospital would get.

At the moment, we pay a hospital by the admitting diagnosis of the patient and the reference cost set by the average length of stay across the country in previous years. The difficulty is that in the population I have described, if the admitting diagnosis happens to be a urinary infection but they have rheumatoid arthritis and had a stroke last year and so on, what determines how long they stay in hospital is not the fact they came in with a urinary infection but that their dependency is much greater than someone who came in who just had that infection.

We are quite advanced in our work to look at perhaps disaggregating the tariff so that you can identify a section of the tariff that is based on the patient’s needs. That work is ongoing. Many CCGs, and PCTs beforehand, were already looking at releasing moneys and sharing the budget with the community.

Q282Dr Wollaston: So it can be moved.

Professor Willett: You can feed it in, whatever way your local services are set up. If early supported discharge is the model that you have made work locally, you can feed that in. It may be intermediate care beds; it may be moving patients early into a care home, but those opportunities are created. We are looking to create opportunities so that we can present to clinical commissioners locally who design local services opportunities to do it in the way that they wish for their patient groups.

Q283Dr Wollaston: Organisations can talk to each other, but, unless the money follows the patient to the right place, it is difficult to see how we are going to see it work.

Professor Willett: Our expectation is that we will have models worked up for that to test the currencies next year.

Q284Dr Wollaston: So next year we should be able to see that.

Professor Willett: I cannot guarantee that because we are working that up, but that is our intention at the moment.

Q285Valerie Vaz: Minister, I want to turn to work force issues. Are you the Minister with responsibility for work force issues?

Earl Howe: I am not, actually.

Q286Valerie Vaz: Who is?

Earl Howe: It is my colleague Dr Poulter, but I will do my best.

Q287Valerie Vaz: You are going to get some questions on work force issues, and I hope you can answer them. I do not know whether you are aware of the evidence given by the College of Emergency Medicine as to the shortfall in trainees for emergency medicine. There are two issues: trainees as well as consultants coming through, and there is a shortfall in both areas. Can you deal with what the Department are doing to address those two issues?

Earl Howe: Yes, certainly. First of all, we were very conscious of this issue as far back as 2010. We asked members of the College of Emergency Medicine to establish the emergency medicine task force, which I think they did in September 2011, to address work force issues in emergency medicine. They published their initial report last year and made a number of recommendations. Those included increased flexibility around core training and the way it is configured and delivered. That included looking at the entry requirements for core training and recognising transferable competencies of trainees currently in other specialties. They were trying to see how one can be flexible in this area, but also how to develop alternative routes into specialty training, such as a parallel run-through training programme. They looked in addition at the expansion of training for clinical nurse specialists and physician associates, trying to define roles rather more precisely, because it is quite clear that the day-to-day delivery of emergency department care is going to depend on the expansion of those kinds of roles.

Health Education England has also set up an expert group, which I think met for the first time in April of this year. That is working in close collaboration with the College for Emergency Medicine and others, to look at what more can be done to ensure there is a sufficient medical work force being trained for the specialty of accident and emergency. We await their advice. It is very much centre stage. Part of the problem here is that it is not an attractive specialty for many trainee doctors for a number of reasons: the lifestyle is pressurised and there are fewer opportunities for private work. To expand the numbers is not a simple matter.

Q288Valerie Vaz: Why is that?

Earl Howe: Because of those unattractive features of the life, if I may put it that way.

Q289Valerie Vaz: But they gave evidence that this has been happening for the last three years. There is a 50% shortfall in trainees, and therefore consultants, coming through. What is the Department doing? What steps are you taking? There is another task force. I am sorry that you are having to answer questions that are within someone else’s remit, but you must be taking some steps.

Earl Howe: Absolutely. Health Education England is the body that we have charged to take control of this, which they are doing; they are gripping it.

Q290Valerie Vaz: When will they report?

Earl Howe: I do not want to give you a wrong answer. I will correct myself in writing if I am wrong, but we expect them to give us some preliminary indications by the autumn on how this can be dealt with.

Professor Willett: Can I add to that because I have been involved in some of it? There are plenty of numbers, in that they are funded and the posts are there. Our difficulty is that less than 50% in three consecutive years have not been taken up. As doctors qualify, they are recruited into core training, which covers a lot of acute areas of health care, including anaesthetics and other areas. At the end of that, a limited number of doctors-I would have to disagree with Earl Howe-do not take emergency medicine. I think it is an attractive specialty.

I am not in emergency medicine; I am a trauma surgeon, but I have lived in that environment for 30 years. There is probably no more rewarding environment, but it is tough. We have to recognise that the nurses and doctors who work in emergency departments are some of the most resilient staff around. When we hear words like "crisis" and "we’re in trouble," we have to take that very seriously because these people can really take it. These are very special people.

All the training numbers are available; they are just not being selected. It is not that there is not enough money to train them. For every two trainee numbers available, only one is adopted. That is partly to do with the task force. When it made its interim report at the end of last year, it indicated that it had a lot to do with the experience of working in emergency medicine; the amount of consultant support they could get, because everything was just so busy; and clearly there are social issues about working in that type of environment.

Nearly all of the recommendations it came up with have moved forward. It is piloting a change in the order of sequence of training posts that are done in that core training; it is looking at transferable skills so that people who train in another specialty can transfer in with greater ease rather than having to start at the beginning again; it is also looking to deal with non-medical issues around other professional groups that work extremely well and now make up a large part of the emergency work force.

We are looking at recruiting overseas as well and have had some success in India, but emergency medicine is quite a British/American model of care. In a lot of countries they do not have emergency medicine; that is not a structure they use. When you arrive at a hospital, you are either taken directly to a specialist department or the specialist department receives you.

One of the other issues we look at is how you are received in the emergency department. We can directly identify some patients who need to be seen by a cardiologist or have other issues, and we reserve emergency medicine for the particular areas they are in to make the thing attractive. We can also link it as a specialty, to take out some of the heat, if you like, with things like critical care-I do not say it is any less hot, but it is more structured-and the prehospital faculty of medicine, which has now been approved as a training programme, so that we can move doctors out into the community to work as emergency response teams. All of that makes it attractive.

Q291Valerie Vaz: I accept all that. You are doing lots of wonderful things, but clearly there has been a crisis, and where you have to get locums in it will cost the NHS much more. I presume this pool of Army doctors who are very used to these kinds of areas will then fit into the National Health Service. I suppose that I am trying to push you into saying what incentives you are actually putting in place now.

Earl Howe: Solving the numbers problem is not going to happen immediately, although one can, as Professor Willett said, look to bring in people from overseas; I think that is being done in certain areas. However, if we are going to have home-grown accident and emergency specialist doctors, we are looking at a period of years before we can ramp up the numbers. Incentives and salary structures are very important; all of that is being looked at by Health Education England. While I cannot present you with an overnight solution and I recognise the problem, we are certainly trying to grip it as tightly as we can.

Q292Valerie Vaz: I have one quick question about the rate of attrition in A and E compared with other specialties. Do you have the figure for that?

Professor Willett: That would be a Health Education figure. I am afraid I would not have that.

Earl Howe: I am sorry, but I do not have it.

Chair: Can you write to us on that? Sarah wants to come in next, followed by Charlotte and Rosie, but we need to be quick, please.

Q293Dr Wollaston: Isn’t it also time that we started disincentivising some of the specialties? We are training too many doctors in the wrong specialties. That has been going on for years. Partly it is due to the factors that you have already identified-there are some very popular specialties where there are very lucrative private rewards to be had. Isn’t it time that we just stopped making those the ones people keep going into?

Earl Howe: If you talked to the royal colleges, they would say the same thing. I defer to Sir Bruce here, but increasingly they are recognising that very issue. We know that we have too few GPs. The numbers are going up, encouragingly, but they are not high enough. We do not have enough accident and emergency specialists in hospitals. There are other specialties where we have shortages. So, yes, that is an issue. We can point to a sort of global figure. We now have more doctors in the system-6,000 more, I think, since 2010-which is good, but maybe they are not quite in the right places.

Q294Dr Wollaston: But it goes right back to medical schools-the way in which medical students are being encouraged to think that there are only some specialties that have value. The emphasis that goes in right through their training is in the wrong specialties. I do not know whether Sir Bruce also wants to comment on that.

Sir Bruce Keogh: My only comment would be to say that I agree with you. The colleges-

Q295Chair: Do you need to add to that? That is clear.

Sir Bruce Keogh: No, I will not.

Dr Wollaston: We have been talking about this for years, but still nothing happens. Medical students are still being taught and incentivised in the same way into the wrong specialties after training. When is that going to change?

Chair: In truth, it is probably a question for Health Education England rather than for this panel of witnesses.

Q296Charlotte Leslie: From a number of sources looking at this, a number of doctors have suggested to me that the European working time directive and the disbenefits that that presents, often in making doctors more tired, with the shift rota system, and disturbing patterns of work-so not being successful in its aim-are more acutely felt in emergency services. While emergency medicine may not be a very attractive option because of the pressures, the working time directive makes it even more unattractive. Are you doing any work on that?

Earl Howe: The Department for Business, Innovation and Skills is leading our efforts in Europe to try to achieve greater flexibility on the working time directive, as I expect you know.

Q297Charlotte Leslie: Have you done a specific assessment of how it may be impacting on recruitment to emergency?

Earl Howe: Impacting on recruitment-I do not know. I think it might be a good idea for us to take away that question, in conjunction with the question on attrition rates, to see whether we can pin any of the attrition on the working time directive. I do not know whether my colleagues are able to provide the answer.

Q298Chair: Presumably, what is true is that the Department of Health is doing work to contribute to the broad Government programme on assessing the effect of the working time directive on training programmes for doctors-presumably.

Earl Howe: Yes, undoubtedly. We are clear-and we have had this message loud and clear from the health service-that the working time directive inhibits optimum care in many areas and is not necessarily beneficial for doctors in every respect. We have to say that there are some areas of the working time directive that have been very good, because-

Q299Valerie Vaz: You do not want tired doctors.

Earl Howe: We do not want tired doctors.

Q300Charlotte Leslie: The new deal prevents that, with the 56-hour limit.

Earl Howe: But there are inflexibilities in it that I think are unhelpful for all.

Q301Rosie Cooper: Professor Willett, a short time ago you described some potential changes to A and E, perhaps with people going direct to specialisms. I wonder whether that model of care relies on rationalisation of 24-hour, around-the-clock staffing and, perhaps, a move towards the trauma centre model. Does it? If so, how much have you progressed that work?

Professor Willett: Reconfiguration of services and reducing the number of hospitals you have to staff is an obvious way of dealing with the manpower issue. The question is, is that actually what we want? In fact, we know that one of the other specialties we have a problem with is acute general medicine-the physicians behind the A and E, as it were, who will take you into hospital. That is another very challenged area where work intensity and patient numbers are very high, and where we are having difficulty recruiting. So there is definitely a link between the two.

On reconfiguring, we know-and there is good evidence-that, as Sir Bruce said earlier, when we regionalise and bring together certain diseases, illnesses or injuries into specialist centres, where we can give not 12 or 16-hour but 24-hour specialist input, there is a dramatic improvement in the outcome for patients.

We know, for instance, that, if you have a certain type of heart attack and go to a specialist heart centre, your mortality rate is 5% rather than 12%. We know that, if you have a stroke and get to a specialist centre very quickly, your chance of severe disability is half of what it would otherwise be. Today the figures have come out on major trauma, for which we introduced specialist centres last April. It looks like we have a 24% improvement in survival for patients with major trauma. These are some of our most critically injured patients, who are moving past one or two hospitals and arriving at a major trauma centre. It is our responsibility to ensure that we offer those sorts of things to patients.

We also have to balance that with determining what things we should not move away from the locality and which diseases and illnesses should really be managed locally. That is what we are doing in the review. We are trying to put out there the evidence for the things that we know we should regionalise and for which we should have a regional network structure, and for those things that quite clearly should be available to local people in their local emergency facility. That is the discussion we have got to have; it is that redesign that makes us creative. What we have heard, and the evidence you have heard from others, is that at the moment we do not have the right fit. We have patients with the wrong things in the wrong places. It is not the patients’ fault; it is the way we have the system designed.

Q302Rosie Cooper: When do you think you will fix that bit?

Professor Willett: We have done some of them. London has done stroke; the rest of the country is following. We have done most of the heart attack. In vascular surgery, mortality for major aneurism surgery has come down by two thirds. That has been done. Stroke has been done and major trauma has been done. We did it many years ago for things such as neurosurgery and paediatric intensive care. Those things take time, but we need to build them into networks.

Q303Rosie Cooper: Do you have in the Department even a broad blueprint for when you want decisions on each of those to be taken by?

Professor Willett: I am not in the Department-I am in NHS England-but I know what you are saying. We are going out now to have what Sir David Nicholson called the "big conversation" with the public, because this is something that will be very difficult for a lot of people to understand. We have to create a system that presents a very simple, straightforward model to the public so that they know how to access health care by one or two routes-111 and 999, let us say.

Rosie Cooper: God help them.

Professor Willett: So we will present a very simple system. Behind that, we have the multi-tiered, complex medical model that will respond to their needs, however and wherever they present. That is the redesign that we need to do. I have to say that 111-phoning first-is absolutely critical. When you recognise that, in the system that we have, different things will be available in different sites in the future, it is really important that we can direct patients to the right sites, so that you get the right care, from the right person, with the right equipment, the first time they arrive, which is a phone first phenomenon. That is recognised internationally and is being implemented everywhere.

Q304Rosie Cooper: What happens if you are like my dad and you are deaf?

Professor Willett: The system is designed to help.

Rosie Cooper: I am sure.

Chair: Can we move on to delayed discharges? Andrew Percy wants to ask about the effect of delayed discharges on the service.

Q305Andrew Percy: Barbara Keeley raised the issue of social care and painted a picture from her constituency. In my constituency the picture is quite different, in that there has not been any reduction in social care intervention levels. At my request, the local authority is actually funding free home visits for over-75s, something we saw when we were in Denmark and Sweden. I have asked it to do a pilot, and it is starting that. It is doubling the number of step-up, step-down intermediate beds, with a £3 million investment, fortunately in my own constituency. However, we have still seen the same pressures on the local hospital. While we have not seen reductions in social care, because the council has made the right choices rather than the easy, simple choices, we have still seen big pressures on the local hospital.

The image that is often created is that there is plenty of access through the front door but very little exit through the back door because of reductions in social care, which I think is a somewhat simplistic connection to make. However, we heard a different message from the people who are actually delivering social care-from the LGA-when they came. They said that delayed discharges attributed to social care are actually falling. Given that there seems to be this strong disconnect between the argument on one side and that on the other, what actual evidence does the Department or NHS England have about delayed discharges as a result of social care failures?

Earl Howe: Again, I think it is instructive to look at a five-year period. If you look at where we are now compared with five years ago, the long-term trend on delayed discharges has been favourable. Numbers and patients are reducing; they are now broadly stable. On the scale of the challenge and the causes of delayed transfers, about 3% of total bed days are due to delayed discharges, with approximately 2% of occupied beds being delayed. So the long-term trend has reached a plateau. It is sticking at around the level of 2,000 acute patients. Before, it was around 7,000.

Q306Chair: Are you really saying that only 2% of NHS beds, on average, are occupied by people whose discharge has been delayed?

Earl Howe: Correct. That is the figure I have.

Q307Chair: Is it a figure that a typical NHS trust would recognise?

Earl Howe: Yes, I think so, although obviously that average masks a range of figures, depending on where you are. That is the official figure that I have been given in my brief. Around a third of NHS days delayed are attributable to awaiting further NHS care. The proportion of overall delayed days attributable to social care is coming down and the proportion attributable to the NHS is rising. I think the evidence you have had from the LGA is right, but it reflects a different mix of factors in the equation.

Andrew Percy: It would be helpful if we could have those figures provided to us again, perhaps in writing, with as much detail as possible, because it is regularly thrown at us that it is all because there is a big issue with social care reductions and that is the reason we are seeing these pressures. As I said, I always think that is a bit simplistic, but the figures do seem quite incredible compared with what we have heard from other people giving evidence.

Chair: It would also be interesting to know what the definition of a delayed discharge is in the context of those statistics.

Q308Andrew Percy: My only other question would have been my follow-up on the issue of beds. I was quite reassured, in a way. We have seen a lot of bed reductions in my own constituency, which has certainly had an impact on people’s ability to access local services in a local hospital. As it happens, this has affected mental health beds, in particular, so that now when people go into crisis, the first thing they do is tip up at A and E.

If we are going to see bed reductions, because that is something that trusts are able to do themselves, without requiring even the consent of the overview and scrutiny boards-they cannot even be called in to the overview and scrutiny boards-how will the Department monitor those? I understand the trend and the reasons for it, but I would say that the failure is that we have taken away bed numbers but have not provided proper alternative pathways in every locality.

Who takes responsibility for that? What will be done to ensure that, if there are going to be bed reductions in trusts, which trusts seem intent on continuing to pursue, there are proper, alternative and robust pathways in place to replace them-not simply to get you home, so that you probably tip up again at A and E?

Earl Howe: There is no single answer to that question, because once again it depends on all parts of the system working together. We get back to the urgent care boards and the work that they are doing. We recognised that, for example, there needed to be extra resources in the system for reablement of frail elderly people. We have put in £300 million over the spending review period to do that, and in many areas that has reaped very valuable dividends.

However, we think there is a lot of mileage in GPs working to ensure that we keep people out of hospital when they don’t need to be there; usually they don’t need to be there. Where this has been successful, in a number of areas I have visited, GPs have got together and identified where they need to target their efforts. For example, on care homes, they go to care homes, educate the staff there to ensure that exacerbations in diabetic patients and those with COPD and so on do not happen, and that falls are prevented; there are very simple ways of reducing falls. All those simple things can be done to prevent hospital admissions. That is where the mileage will be seen most over the years ahead.

Q309Andrew Percy: You raise the issue of care homes. Because care homes have come up, I want to jump ahead a little bit to the ambulance service, and it raises the issue of tariff again. I met one of my local ambulance services recently; I have two that cover my area, Yorkshire and East Midlands.

One of the chief executives explained to me that there is an awful lot of work they could do with a lot of their regulars in care homes, which are a huge demand on the service; there is no doubt about that, as you have identified. But doesn’t the tariff work against that for the ambulance service, as the fewer people it transports to A and E, the less money it gets paid? Is the tariff being looked at, to reward ambulance trusts for reducing their regular calls? They do not really get a financial reward for that at the moment, do they?

Professor Willett: The tariff has been restructured. Rather than an ambulance service being paid just for conveyance to hospital, it can be paid for receiving the call, for hearing and treating-in other words, managing by advice down the phone-and for seeing and treating. Those currencies have been agreed.

Q310Andrew Percy: I understand that. The point is that, if the trust works to negate the necessity for a call at all, there is no financial incentive for them to do that, is there?

Professor Willett: The currencies have been worked up. At the moment, those are managed locally, so that is for local discussion. If the CCGs-which, as we have said, are commissioning the whole pathway now-want to utilise it in a way that encourages the ambulance service to do more of that, they can look at that part of the contract; the currencies are available to do that. My understanding is that, at the moment, the prices are delivered locally. Although the currencies have been set nationally, the prices are local.

Dame Barbara Hakin: Can I go back very briefly to the previous question about planning? Every year the NHS undertakes a sophisticated planning round, where the commissioners-in this case, CCGs and NHS England-work with all local providers to identify all the initiatives and the number of patients who are likely to be admitted both electively and urgently. They work with the acute providers so that, on that basis, they can determine the number of beds they need.

Quite rightly, you point out that, if the planned initiatives to keep people at home do not work swiftly enough, you run into a problem with your bed numbers. But I think it would be wrong if we left without the impression that the NHS goes through a very sophisticated process of planning every year, matching the different services and making sure that the numbers add up.

Q311Chair: Can I bring this back to the discussion we had about delayed discharges? Within that work, it is important not just to look at numbers within existing systems and measures of narrow definition of delayed discharge, but to look at work flow in order to use effectively all the stages in the hospital and community services, isn’t it?

Dame Barbara Hakin: I agree absolutely. As I go round the health service, I often find that the provider-I am sure you have been talking to the same chief execs-will say that there are significant numbers of patients in their hospitals who, if only they had the full range of services at home, would not need to be there. We need to look at everything in community and primary care services, not just social care-and the systems within the hospital, because sometimes we hear stories of patients who could go home sooner if something that is going on within the hospital itself were more effective.

Chair: A report published by the Health Foundation earlier this year suggested that, for one luckless patient who spent eight days in hospital, 18% of that time was clinically useful.

Q312Andrew Percy: To follow up on the question about mapping, does that mapping factor in at all the experiences, as they may be different for urban versus rural patients? We hear a lot of talk about alternative pathways and how they are the key to all of the problems here, but the reality is that those alternative pathways are much more likely to exist in an urban setting. We heard in the debate in Parliament a couple of weeks ago about urgent care centres, walk-in centres and all the rest of it. For my constituents, who are largely rural, that is not an alternative pathway at all. Is that considered at all?

Professor Willett: This is a really important area. Going back to where we talked about reconfiguring services, one of the disadvantages of regionalising services is that we create more areas that are more rural, if you like, than they were before. We have to look internationally, and we are. One of the things NHS England will do is appoint a national clinical director for remote and rural care and services to focus particularly on this, which we have not done previously in the NHS.

If you look internationally and at the things we will need to look at across this pathway, one thing is to make sure that, when you have an emergency, the sophistication and skill mix of the attending people at the start is higher. One way to keep people at home, to manage them at home or to manage them at the scene of the accident is to have someone such as a paramedic with extended skills attend that scene. They can do a lot of things.

What a skilled paramedic can do in an ambulance now is most of what we spent the first 30 minutes doing in A and E 10 or 15 years ago, so the options are very different. One of the things for remote and rural communities is to supply at the scene in an emergency the skill set that is most likely to be able to maintain the patient there or to temporise until the local general practitioner arrives. The general practitioner services in rural areas are very much more involved in going out to treat their patients.

When we look at remote and rural services for a lot of the follow-on and other care, one of the things the review will need to look at is how we create the right emergency and local facilities that will mean that patients have to travel for the least amount of time that is necessary. So there are certainly things that we will be doing.

Dame Barbara Hakin: Yes, but the mapping services are done locally. While we obviously do national modelling, the key part of planning goes between the CCGs and the local providers, so services will be planned for the specific area, whether it is urban or rural.

Chair: That is a neat link. We need to move on to the next question, which Rosie was going to ask about GPs and primary care, and their role in urgent care.

Rosie Cooper: Are we at question 17, Chair?

Chair: Yes. That is where I am.

Q313Rosie Cooper: It is something that links in neatly to the rural aspect of Andrew’s question. When commissioners propose the closure of a walk-in centre, what provisions must they make to cater for patients who will then have to seek treatment elsewhere? I have seen the document by NHS England that suggested that walk-in centres and minor injuries clinics should be near A and E departments.

What happens to patients who cannot get to those clinics? Many of my constituents cannot travel; the means of travel-buses and so on-are not there, and they struggle to access services. What should commissioners be doing about those people? The question is two-pronged. First, what must you do to cater for the patients who will need to seek treatment elsewhere? Secondly, how do you make sure they can actually do it?

Professor Willett: Again, we are talking about different models for different areas, which is why it is really important that the local commissioners own their services. The comment that was made about urgent care centres being aligned to what are currently traditional A and E departments is based on the fact that we know that that model works very well. It is the most efficient model, as patients who arrive at a setting can be triaged into the right pathway. There is also the ability for the general practitioners who are running the urgent care centre and, perhaps, the emergency nurse practitioners to work across both-and for patients to move across both. Inevitably, getting a patient to the right place is a matter of judgment, and very often that may turn out to be wrong. This gives you the opportunity to address that.

Quite clearly, that does not apply for rural settings. You will need to have a local emergency or urgent care facility to deal with the needs of the patient locally. You do not want patients to travel long distances when they do not need to. It is around creating the services that best supply what a patient can have in their home or as close to it as possible. That may well be an urgent care centre or equivalent in a locality in a rural area. We are not suggesting otherwise; we are just saying that it is more efficient in the urban areas.

Q314Rosie Cooper: What if the local commissioners decide to close one? What provisions must they make for the local population?

Professor Willett: They have to look at the needs of the population and ensure that they can be addressed. You mentioned walk-in centres. The walk-in centres were predominantly an out-of-hours primary care function, not a minor injuries unit or an urgent care centre. This plethora of names is one of the problems that the current system has, which is why it needs to be redesigned. One of the issues is that patients do not know what they can get at a walk-in centre, an urgent care centre and an emergency care centre or minor injuries unit, so they end up going to A and E.

Q315Chair: Do you know?

Professor Willett: Why would I? If I were on holiday, no, I would not. In the locality I might know if I happened to use it, but if I were on holiday or on business I would not. This is why the system needs to be redesigned. We need to start with the patient’s needs. I am afraid that is why a phone first system is essential. Let us give you bellyache, for want of a symptom. If you have that, you do not know whether you need to pass flatus, whether you have a serious abdominal problem or whether you have appendicitis. Why should you-and why should I-as a patient? Rather than have you turn up at a facility, having travelled there, that does not supply it, phoning first and getting some advice so that we can steer you to the most likely point-

Q316Rosie Cooper: And talk to a pen pusher who does not have a clue either, who has a script, will not listen to you and just keeps following the script-

Professor Willett: No-

Q317Valerie Vaz: Why have the call centre then?

Professor Willett: Because the pathways that the call centres follow have been designed by the royal colleges. This is all clinically designed. The call centre has a call centre handler, who will refer you on, based on the algorithm. What they make sure of is that they are not missing something serious.

Q318Valerie Vaz: They refer you to A and E.

Andrew Percy: No, no, they do not.

Chair: Order. This is not a discussion.

Professor Willett: Shall I continue my evidence?

Chair: Please do.

Professor Willett: My evidence would be that the call centre has call handlers who are trained and are following pathways designed by the clinicians, from the consensus group of the royal colleges. If the algorithm that they are following indicates they need clinical advice, they will refer them directly-only occasionally do they need to be called back-to a nurse, who will then take over. That is how it works.

Q319Chair: With respect, the reason why you were being interrupted was that you set out how "it works." The question is whether in practice it does work. If it does not, what is being done to ensure that it will work in the future?

Dame Barbara Hakin: I will take over on that. There is no question whatever but that we had serious problems with NHS 111 in the early part of the year. In particular, a couple of providers failed to deliver the service for which they had signed a contract, having given assurances that they could deliver the service. At the time, we had to step in to remove some of the volume of work from them and to support it with contingencies from other areas.

Now we are seeing a dramatic improvement in the response times and the call handling. For virtually the whole country, seven days a week, we are seeing the standards met. We have two key standards for answering calls. The first is that 95% of calls should be answered within 60 seconds. Over the last two or three weeks, that standard is being met virtually everywhere in the country. Another one, which I think is really important for patients, is the number of calls that are abandoned-very few calls should be abandoned.

We have now reached a position where, across the country where 111 is operational, the calls are being answered quickly and calls are not being abandoned. We are also seeing much improved transfer times to nurses. The vast majority of calls to NHS 111 are handled by the call handler, so the number of times-

Q320Rosie Cooper: Is this a secret way of getting everyone to use private medicine, so that you can actually speak to a doctor and deal with real people instead of a pen pusher?

Dame Barbara Hakin: I think it would be fair to say that the majority of our telephone response has not been done by doctors. Doctors do not answer the phone in the out-of-hours services; they do not answer when you dial 999-

Rosie Cooper: That is why people turn up at A and E.

Chair: Rosie, order.

Rosie Cooper: Sorry.

Chair: Can we conclude on NHS 111? We will come back to GP services.

Charlotte Leslie: I know that Sarah had some questions that we have jumped over to come to this section-

Chair: Do you want to go back to general practitioners first?

Charlotte Leslie: I would be very happy to, if Sarah would like to do that.

Q321Dr Wollaston: Going back to the issue of primary care, we know that, if you cannot get an acute appointment with your general practitioner, you are more likely to turn up at an A and E department, particularly if you live nearby. Could the panel outline what is being done to improve emergency access in primary care, where that is the most appropriate venue for people to be seen?

Dame Barbara Hakin: It is certainly a significant issue. It is sometimes an issue when patients have rung to get routine appointments for things that they do not see as an absolute emergency but where they feel they need to be seen over two or three days and they cannot get an appointment with their GP. Keith described the confusion that exists and asked, "Why wouldn’t I turn up at an A and E?" The same applies to patients who cannot get an appointment with their GP-they will go to A and E.

We have a number of things in the GP contract to try to improve and extend urgent access for patients. We measure and check that patients can be seen quickly when they need to be and should still be seen swiftly by general practice. This year we will have another round of negotiations with the general practitioners committee, as we do every year. We will look at a range of things, but doubtless those will include ensuring that patients have good access.

As well as looking at the urgent care strategy, one of the areas overlapping with that at which we are looking very much is the primary care strategy. As part of NHS England’s wider look at the future, it is looking at what the future of primary care-general practice, in particular-should look like.

Professor Willett: Can I add something from a clinical perspective? There are various models out there that are already working. You may be familiar with the doctor first model where, rather than everybody having to be seen with an appointment, you phone and speak to a doctor, who will frequently be able to arrange something different or to deal with the issue over the phone. That creates more capacity within primary care, because that appointment takes up a lot less time.

That is also another thing the urgent care boards will be looking at, because they will be looking to accelerate in those areas where currently things are not working well. For instance, for all the criticism that has been levelled at 111 services, if they are set up with a very good directory of services, when a patient phones, they can direct them to a pharmacist that they know is open and can deal with that prescription issue, rather than a GP appointment or to A and E, which is what happens currently.

Those are the sorts of things that the urgent care boards are doing. In the wider reconfigurations and redesign of the service, those are the sorts of elements that need to be looked at. There are some really good practices out there. Some general practices have really changed the way in which they manage patients. Others have yet to do so, but that is what we are trying to encourage everyone to do.

Q322Dr Wollaston: Of course, the same work force crisis issues affect general practices.

Professor Willett: That is another reason why we have to use the GPs’ time optimally, because they are really important in primary care. As you will be aware, there are something like 300 million primary care consultations each year. Maybe a third of those are urgent. It needs a very small change in that 1% that we know about from the GP survey of patients. We know from that survey that 16% of patients have tried in the last year or so to make an appointment and have not got one.

Overall, 1% of those people who were trying to get an appointment end up in A and E. That is actually a very large number out of the 300 million consultations, even if you look only at the urgent care component. That is the sort of thing that may well change a lot of the pressures we see on the ambulance service, then on A and E departments, then on hospital beds and then on social care. That is why it has to be a system-wide redesign.

Q323Charlotte Leslie: I would like to go back a bit on 111 to get to the bottom of some of its background and birth-who was responsible and how. Dame Barbara, I would like to come to you first. How long have you known David Nicholson?

Dame Barbara Hakin: Probably about 10 years.

Q324Charlotte Leslie: Congratulations on your new role. When did you apply for your current role?

Dame Barbara Hakin: I didn’t-there was not an application for the role.

Q325Charlotte Leslie: Were you approached?

Dame Barbara Hakin: Yes.

Q326Charlotte Leslie: Who approached you?

Dame Barbara Hakin: I have an interim appointment, in that the then Chief Operating Officer, who would have been responsible for all the operations, was leaving at the end of April. I was asked whether I would be prepared in the short term to take on this role. My previous role, which is still my substantive role, was as National Director for Commissioning Development.

Q327Charlotte Leslie: But who approached you?

Dame Barbara Hakin: Sir David Nicholson asked me.

Q328Charlotte Leslie: When you accepted the role, did you notify the Secretary of State and introduce yourself in your new role before it was made public?

Dame Barbara Hakin: I know the Secretary of State and had been in meetings with him before that.

Q329Charlotte Leslie: So you did introduce yourself to him in your new role prior to its being publicly announced.

Dame Barbara Hakin: I do not recall that I actually spoke to the Secretary of State in that time.

Q330Charlotte Leslie: So you did not introduce yourself to the Secretary of State prior to its being publicly announced.

Dame Barbara Hakin: No.

Q331Charlotte Leslie: Going back a bit more, were you surprised to be given that role, given that you were facing possible investigation by the GMC?

Dame Barbara Hakin: I have always strenuously denied the allegations made against me. I have given evidence to this Health Select Committee that my actions were always in the best interests of patients and always in the interests of ensuring that patients did not wait too long in A and E departments, ill on trolleys. I think it would be unfair to assume that these unproven allegations are correct. I deny them and welcome the opportunity for the GMC to look at this, because I am confident that it will recognise that I always acted in the best interests of patients. I always have done in the 40-something years since I came into health, when I first went to medical school.

I think now is a time when experience is really important. It is a difficult time for the NHS. I have been a GP, I have run a PCT, I have run a strategic health authority and I have significant operational experience. I would also suggest that, since I took on the role, 111 has stabilised and improved and we have seen an improvement in A and E. I think it is reasonable that Sir David should choose whom he saw as the right person as an interim appointment. Plainly, if the role were substantive, it would be absolutely different and we would go through a proper appointment process.

Q332Charlotte Leslie: So you would not be deregistering from the GMC.

Dame Barbara Hakin: I would not deregister from the GMC. I am proud of the fact that I am a doctor by background.

Q333Charlotte Leslie: Who has been the SRO for 111 since its inception-in 2009, I believe?

Dame Barbara Hakin: The SRO transferred to the Chief Operating Officer of NHS England in November last year. I became the SRO for 111 as at April-at the beginning of April. I am struggling to remember who was the SRO for 111-

Chair: If you do not remember, please write to us and let us know.

Q334Charlotte Leslie: It would be very valuable if you could write to the Committee to say who the SRO for 111 was. When was approval for the 111 number to be used given?

Dame Barbara Hakin: I have the details on that, but I will have to look for them quickly.

Earl Howe: The original decision that 111 would be the number for this type of urgent call took place under the last Government, in December 2009. We were very clear in our plans when we came into office that we wished to take this forward, which we did. There was no divergence of view in that regard between us and the previous Administration.

Q335Charlotte Leslie: But who was responsible for that decision and its development in the Department?

Earl Howe: You will have to forgive me, because I took over responsibility for urgent and emergency care only last autumn, when Simon Burns left the Department. I will have to find out what happened at the beginning, because it was not in my purview.

Q336Chair: But the decision to develop NHS 111 was a ministerial decision.

Earl Howe: Oh yes, it was certainly a ministerial decision. Andrew Lansley was very clear that it was a top priority.

Q337Charlotte Leslie: So you inherited it. What was the key intended difference between 111 and NHS Direct designed to be?

Earl Howe: If you telephoned the number for NHS Direct, it would give you advice. This is a much broader service. It is much more integrated as part of the urgent and emergency care system, so that not only do you get advice but you can be put through to a nurse, if you want to speak to a nurse, or to a doctor, if you want to speak to a doctor. They can make an appointment and call an ambulance-it is a much broader range of services.

One of the things that the Foundation Trust Network identified was that part of the problem we are dealing with here is poor signposting. As Professor Willett said, people simply do not know where to turn. If we can urge and encourage people to phone before they do anything, it should get through quite a lot of this confusion that they have. So it is designed to be part and parcel of the urgent and emergency care system, rather than just an add-on advice line.

Q338Charlotte Leslie: I will go back to the mechanics of its inception, if I may. Dame Barbara, your own evidence says, "the small scale of the pilots, along with inconsistent control sites, and the short time frame that the evaluation was looking at meant the conclusions were limited." Given that, why were they rolled out so quickly and the pilots not evaluated? Who made that decision?

Dame Barbara Hakin: A decision was made by the Department in June 2012 that areas could ask for an extension of the deadline by six months, to October 2013. A letter was then sent to all clinical commissioning groups, which were then sub-committees of PCTs, to say that, if they felt that they were not ready or the services were not ready, they could apply for extensions. In the event, locally, only four small areas applied for deadline extensions. They were Leicestershire, Devon, Somerset, and East London and City. So there was an opportunity, where there were local concerns, for people to extend that deadline.

Q339Charlotte Leslie: So why do you think it still went so badly wrong? I do not think that people can deny that it went badly wrong. Were you not doing any due diligence or monitoring of how this was going before you allowed it to be rolled out?

Dame Barbara Hakin: Again, I was not involved at the time. Looking back, I still think that there is no question whatever that certain providers gave assurances that they were ready to take on this service. I have looked at the exchanges between the local commissioners at the time and providers, and the CCGs or PCTs were given absolute assurances that there were sufficient call handlers, adequately trained, to take on the services. You cannot look back at what happened in March and April, when we had real problems with 111, and not say that we must learn some lessons from that. It is not possible to look back and not say that-we did not get the level right.

Q340Charlotte Leslie: When did you first know there was a problem?

Dame Barbara Hakin: When did I first know there was a problem? I think I first understood the gravity of the problem towards the end of March, when I was about to take over as the Chief Operating Officer. At that time, Sir David asked me specifically to take responsibility there and then for 111, which I did somewhere around the 27th or 28th of the month.

Q341Charlotte Leslie: And prior to that you had no responsibility whatsoever for 111.

Dame Barbara Hakin: I had no direct responsibility for 111, but I was a senior member of NHS England and was previously in the Department of Health.

Q342Charlotte Leslie: The general trend is to recognise that, as soon as possible after presentation, a patient should see a more highly qualified skilled clinician. In that context, who decided that it would be a good idea for patients to be assessed initially by people who are not clinically trained but based on an algorithm, where judgment was not capable of being exercised? Who made that decision and why?

Dame Barbara Hakin: The decision in the early inception was to create an efficient service. I think there is a misunderstanding that NHS Direct used nurses to answer calls or that the ambulance service used doctors. What we are saying is that it is absolutely critical that you get clinical advice at the right stage in the patient’s journey very quickly. That does not mean that we have clinicians doing the immediate answering of telephone calls almost anywhere in the health service.

Q343Charlotte Leslie: Forgive me, but does that not feel a bit like what we have seen with the CQC, which boasts success because of the number of people it registers? Don’t we see a system where it is all to do with quantity and not to do with quality? It is looking at the number of people going through the system-it is tick-boxing and is not a focus on quality.

Dame Barbara Hakin: No. As Keith said earlier, the algorithm that is used by the call handlers has been designed by the colleges, across the spectrum of the colleges. It is designed to give patients the swiftest and best possible treatment. Unlike NHS Direct, 111 can dispatch an ambulance immediately; it has access to that ability. If the call handler going through the algorithm determines that the patient needs an emergency ambulance, it will be dispatched instantly. The clinical professionals are necessary to come in and support call handlers. On the whole, there is one nurse for approximately every four call handlers.

Q344Charlotte Leslie: But given what we know about early intervention of clinical expertise, why would you not roll out that principle to your immediate point of entry into the care system in order to sift out those who are not needed? Why would you not put more clinical expertise at the front line?

Professor Willett: If you sat in a 111 centre, an NHS Direct centre or, in fact, a 999 centre and listened to the calls coming in, you would see that the amount of medical or nursing time that would be inappropriately used was enormous. What a patient perceives to be an urgent problem for them may well not be medical.

People will phone up because they have gone on holiday and forgotten their tablets; a whole range of things come through. What is appropriate is to have an algorithm, which frustrates people, perhaps, but recognises that there is not a life-threatening event. I know that it is difficult for people when they are standing there saying, "But I am phoning up only because I have forgotten my contraceptive pill," and you ask, "Are you breathing?" But it is built to be safe and to give you the right medical input-clinical input or nursing input-at the first point where it becomes appropriate. That is how you manage the millions of calls that come into these systems.

That is being worked up now. We are looking at it-there is a group that looks at it the whole time to review the appropriateness of the algorithms. Obviously we may be overcompensating, because it will be built on a cautious system-it will be safe first-but that is the system that has been put in place. Internationally, it is what would be used.

Valerie Vaz: But you are advertising the system as a call centre that people should ring, irrespective of what they need or want, as they will then be directed to the right service. You are asking people to do that-to ask, "What do I do about my lost pills?"

Q345Chair: You have been saying this morning that urgent and emergency care needs to rely on the principle of phone first. I have listened to this description of a service that involves getting to urgent and emergency care by a phone first service that requires you to go through an algorithm. Is that to be the future of NHS urgent and emergency care?

Professor Willett: That is what the review is looking at, but I would be very surprised if it is not a component.

Earl Howe: I am aware that the system is capable of putting patients with specific needs straight through to the right person on a fast track. I do not think that that applies everywhere yet, but it does happen. For instance, if you need a catheter or something like that, you can be put straight through to someone who will attend to that.

Q346Chair: Has it occurred to anyone in the Department that, if the choice is between going through this kind of talking to a human computer option or going to an A and E department, people may just prefer to walk into an A and E department?

Valerie Vaz: Absolutely.

Earl Howe: Let us get this slightly in proportion. We did not just launch into this without trying it out. There were pilots. One of the key metrics from those pilots was patient satisfaction; 92% patient satisfaction emerged from the pilots. Those were people who said that they had had a good or excellent service. There were also very high levels of approval from people who said that they had been put through to the right person first time.

Q347Valerie Vaz: What about the outcome of their medical problem?

Earl Howe: The outcomes were that problems were satisfactorily addressed.

Q348Charlotte Leslie: But the Department of Health already says that the conclusions you could draw from the pilots were limited. A further point of concern is that procurement and tendering for the companies to deliver this were done before the results of the pilots had been seen. Why was the Department embarking on procurement before the results of the pilots had been seen? Because of the set of the pilots, the results they produced were also inconclusive; you could draw limited conclusions from them. Why was that?

Earl Howe: On the point about the pilots being inconclusive, I will simply say that there were mixed findings from different pilots as to the effect on A and E, the effect on GP appointments and so on. They were inconclusive in that sense because we had different results coming in from different parts of the country, but there was absolutely no doubt that there was a high degree of patient satisfaction in all the pilots. That is what gave us the confidence to know that this model worked and was efficient and effective. I think that drove the decision to roll the thing out.

Q349Charlotte Leslie: I think reality has proved differently. If I may go back, why were procurement and tendering taking place for the pilots without the publication of the evaluation? Why were you procuring 111 services from organisations and companies? What due diligence did you do on those? Why was this done before the evaluation of the pilots?

Chair: Can I put the question in another way? What is the hurry? There was NHS Direct. Ministers have adopted this principle of NHS 111. What is the policy objective that Ministers are seeking to deliver, and why?

Earl Howe: The policy objective was to deliver a better, higher quality service for people who did not know where to turn in the NHS. It was not necessarily to save money-it was to provide a much more appropriate series of pathways.

Q350Chair: What were the points of difference that were being sought in NHS 111 compared with NHS Direct?

Earl Howe: As I said, NHS Direct was simply an advice line-a helpline. You could not necessarily get through to a nurse or a clinician to talk about your problem. It would not let you know where your nearest pharmacy was and would not call an ambulance for you if you needed that. This is a service that should take the heat off 999, once people are educated into using it, which NHS Direct was never intended to do, but it should also get patients to the right place much more quickly. That was the purpose of it.

Q351Chair: That, in itself, is part of the process of a more integrated urgent and emergency care system-I understand that-and is an ambitious objective. Hence Charlotte Leslie’s question: if that development of urgent and emergency service was what Ministers were seeking to deliver, why didn’t they check that they had a pilot that worked before they rolled it out?

Earl Howe: My point is that we did check that the pilots were working in the most important sense-that they were getting patients through to the right service in a very timely fashion. There were a number of pilots around the country.

Dame Barbara Hakin: Were they not in the north-east specifically?

Professor Willett: They were in County Durham and Darlington, Lincolnshire, Nottingham and Luton. They were evaluated by Sheffield University.

Q352Valerie Vaz: Is there a list of all these pilots on your website-the good and the bad?

Earl Howe: Yes, I am sure they are on the website.

Q353Chair: Is it in the public domain?

Earl Howe: Yes, absolutely.

Professor Willett: The Sheffield university evaluation is in the public domain.

Q354Dr Wollaston: When were the pilots commenced, and when did they complete?

Earl Howe: Some commenced in late 2010, from memory. Others started in 2011.

Dame Barbara Hakin: The first pilot was in August 2010; it was in County Durham and Darlington.

Earl Howe: Then there was a succession of others.

Q355Chair: It might help if you could write to the Committee with a summary of the information about the pilots and where those data can be found.

Earl Howe: Yes.

Q356Charlotte Leslie: I am still puzzled as to why, before the pilots were able to be evaluated, the Department embarked on a tendering process for organisations to deliver the scheme. Why wouldn’t you wait until the pilots had been evaluated before embarking upon that, when you could involve the CCGs?

Earl Howe: But we had the work of Sheffield University evaluating the pilots. I have explained the sense in which the results were inconclusive. Those areas were not key to our decision as to whether this was a good or an inferior service. We were clear that it was a good service. The respects in which we needed further data were not central to the decision as to whether to roll it out. It was and is a good service.

Q357Dr Wollaston: So is it the case that the primary definition of being a good service was based on patient satisfaction, rather than actually changing the outcome?

Earl Howe: No, on the outcome as well.

Q358Dr Wollaston: But you said there were mixed results on that.

Earl Howe: Patients were self-reporting on their outcomes, and the reports were very, very favourable.

Q359Dr Wollaston: But in terms of actually reducing A and E attendances or the clinical outcome, there was not evidence from the pilots to show that it delivered a better outcome for patients. Can I be clear about that? There is a difference between a service being popular and a service delivering an outcome.

Earl Howe: I totally take that point. In a number of the pilots, we saw A and E attendances go down in relation to the rest of the country. In other pilots-in Nottingham, I think-we actually saw A and E attendances go up.

Professor Willett: In Lincolnshire, the number of ambulance incidents rose. A and E attendance went up in some pilots and down in others, but overall-across the four pilots-there was a small reduction in A and E attendance. It was not significant, but the pilot was not designed to do that; it was designed to create a system that ensured that patients got to the right place. The option of a directory of services was a key part of it, which meant that you had the opportunity to direct patients to the right service. It was not intended to reduce A and E attendances; it was intended to put in a much better system for directing patients.

Q360Dr Wollaston: The other criticism, of course, concerns the length of the calls compared with the length of calls in the previous service. Is that an issue you are concerned about?

Dame Barbara Hakin: Particularly in the early launches, one of the problems was that, first, there were insufficient call handlers in some places, and secondly, that the call handlers had had not as long in training as they might have had. What we see with 111 specifically is that the call handlers become more experienced and the call time goes down. The average length of call now is about eight minutes, whereas we were hearing of lots of people being on the phone for 20 minutes to answer questions. We continue to see improvements. In the pilots, patient satisfaction over six months was in the 90% range.

Q361Dr Wollaston: The other problem, of course, is that some people were waiting excessively long periods for genuine emergencies to be dealt with. Has that now been resolved?

Dame Barbara Hakin: We have seen that 95% of the calls are answered within 60 seconds. We had a lot of reports of patients waiting for call backs. Sometimes those patients were waiting for call backs from the out-of-hours service, because one of the issues is that in most places a local choice was made to integrate the out-of-hours service and to work with it in 111. Sometimes when patients are reporting a very long time to be called, it is when the 111 part of the service is finished, the patient has been handed on to the out-of-hours service and they are waiting for that call back. None the less, there is no doubt that in the early stages there were delays in call backs from 111.

We are now seeing a situation where 80% of calls are completed satisfactorily by the non-clinical staff, which leaves 20 out of 100 callers to be passed to a nurse. We have now got the numbers up, so 15 of the 20 are passed directly and do not have to be called back at all. Of the five remaining patients, half are called back within 10 minutes. I agree entirely that, to get the service right, we want to see all patients called back by 111 very swiftly, but the numbers now show me that the vast majority of patients who need to speak to a nurse are able to speak to one swiftly.

Q362Dr Wollaston: So 2.5% of people waiting for a call back from the 111 service itself-not the ones passed on to other people-

Dame Barbara Hakin: Not the ones passed on, no.

Dr Wollaston:-are waiting for more than 10 minutes for that call back.

Dame Barbara Hakin: Yes.

Chair: We have run substantially beyond our planned time, but we have not covered ambulance services. Andrew, do you want to ask questions about ambulance services?

Q363Andrew Percy: Very quickly, because I know we are running over. It goes back and links to the comments we have already made about alternative pathways. We have talked somewhat about this already. We have heard anecdotal evidence about the number of paramedics versus technicians. Can you give me your understanding of where we are at in terms of hitting what I think was a target of 70% of front-line staff to be trained paramedics? Perhaps you could respond to the anecdotal evidence.

Earl Howe: There is a general point to be made here first off, which is that it is up to local ambulance trusts to configure their human resources as they think fit; they are free to do that. Different clinical responses will be appropriate to meet different situations. For example, many trusts deploy paramedics in cars as well as in ambulances. Obviously that makes for better flexibility and improved care. There is no overall target as such.

Do we or do we not have enough paramedics? The picture that has been painted for me is that the situation looks satisfactory. The projections by the Centre for Workforce Intelligence show that there is a secure supply of paramedics up to 2016. Currently, there are 900 ambulance technicians who are training to become paramedics, which will result in an increasing number. If one looks at vacancy data, the last figure I have-which, admittedly, goes back a couple of years-showed that the total number of vacancies for ambulance staff had more than halved; it was recorded as 1.7% in 2010, compared with 4.7% in 2009. So the vacancy gap is shrinking.

Q364Andrew Percy: What is the national percentage of staff at the moment who are paramedics as opposed to technicians or any other category?

Professor Willett: I think those data are held locally. I do not think NHS England collects them.

Earl Howe: I know that in 2012 the Health and Social Care Information Centre advised that there were 18,645 qualified ambulance staff in the NHS in England. If we can get you a breakdown of that figure, I will be happy to do so.

Q365Andrew Percy: It would probably be useful, because we have heard a lot about how ambulance services are so important in trying to reduce this demand on A and E and in trying to access these other pathways. Another issue we heard about-I think from the ambulance services themselves when they provided evidence-was paramedics accessing the National Spine and, leading on from that, being able to communicate directly with GPs, to access medical records and all the rest of it. What progress is being made on that? I know that probably the response will be that it is a local matter. I understand that it is, but it needs a real national push.

Professor Willett: You will see that that was one of the key objectives we set out for the review-that information critical to care of the patient should be available to all the professionals in the pathway. We know that is not the case. At the moment, paramedics who are at the scene with a patient who may be a little confused do not have any history, do not really know what is going on and whether or not this is a normal state for the patient, and have to try to contact a GP. So that is quite clearly one of the elements.

Another thing that urgent care boards will be looking at is what is there in their patch, because in a lot of places that is available. We know that in some places the minimum patient record, showing what has happened to them, their key disorders and what has gone on in the last couple of weeks, is not available, but in other parts it is. In some parts of the country, the paramedics and the people in A and E departments can access it, but in other parts of the country they cannot. That is inexplicable and needs to be addressed as part of one of the key themes for patients. Patients cannot understand that. Perhaps one of the things that urgent care boards should ask their membership very seriously is why they cannot do that.

Chair: Perhaps we will not go back to urgent care boards.

Q366Andrew Percy: To conclude-I suppose it is more a comment, but there is a question in it-the ambulance services seem to be a key component of all of this, but I was surprised at how little interaction a lot of CCGs have had with their ambulance providers. In my local area there are two CCGs, and to a lesser or greater extent they instil me with some confidence. However, they do not necessarily seem to be communicating with the ambulance trust. This is something that will be very patchy.

I know we keep going on about local decision making, but it seems to me that this is a service on which a lot of money is spent and out of which we are not getting best value at the moment. It seems that other providers in the NHS-whether it is GPs, CCGs or even hospital trusts-do not really value it or see the potential for it. I really want an assurance that there will be a big emphasis on this nationally.

Professor Willett: This is a new relationship, because the CCGs, being clinically led groups, are very familiar with working with the hospitals and social care in local authorities but have limited direct contact with ambulances. If the ambulance has gone, they probably have not, whereas if they have gone, the ambulance probably will not-or if it does, it will not be when they are there.

As I said, since April, with the new structure of the NHS, the CCGs will be commissioning all the elements of the urgent care pathway. I think this is one of the areas that will naturally become a focus and that the value of the ambulance services and the impact of congestion in the system at various points-and how it affects the ambulance services and the flow that the Chairman mentioned earlier-will be appreciated.

Dame Barbara Hakin: Just a few weeks ago I met Anthony Marsh, the chief executive of West Midlands Ambulance Service, acting on behalf of the ambulance trust chief executives, to talk through-because I completely agree with you-their experience and how we could support the system, particularly CCGs.

One of the things we will be doing in NHS England as part of our support and development for the CCGs is helping them to work collaboratively, because they need to do that for ambulance services. We will work with Anthony and his ambulance trust colleagues to make sure that we get that interaction and that, as part of the CCG development programme, we can support them to be better commissioners of ambulance services, because I agree with you that they have so much to offer in understanding urgent care.

Q367Andrew Percy: Are we clear that the Red 1 and Red 2 target will remain? Again, this is something that has been described as unhelpful. I am a first responder with the Yorkshire Ambulance Service, so I see this myself. I know about the response time. As I said at a previous hearing, a paramedic said to me once, "If we turn up in nine minutes and save their lives we do not get any credit, but if they die and we are there within six, seven or eight everything is fine." I understand the frustration of that, but it concerned me that there seemed to be a bit of a push from some of the ambulance services to get rid of that target. In a rural area such as a large part of my constituency, it is the only thing that means we have any ambulance resources located in the area. Without it, because of the small volume of calls, we would lose it. So I hope that there will be an assurance that the target is here to stay.

Earl Howe: I am not aware of any desire to remove that target.

Professor Willett: I do not think there is, but one of the objectives that are going into the review is that the quality of my care as a patient should be measured in a way that reflects both the complexity and the severity of my illness. The target was brought in specifically to do that. Clearly, we need to make sure that it is current and is doing what it was brought in to do-to fight life-threatening conditions.

Q368Andrew Percy: Absolutely. We hope that that response time would be to get a paramedic there, but is it ever appropriate for technicians to attend to those life-threatening calls when a paramedic has not been dispatched? Again, we have heard anecdotal evidence that this may be happening in trusts around the country.

Earl Howe: It depends on what the call is. The ambulance provider has to make a judgment when a call comes in as to what the need is.

Q369Andrew Percy: What if it is a cardiac arrest? There was an allegation in my local trust by ambulance crews that EMTs were being sent and paramedics were not even being dispatched. The trust says that is not happening. I will not draw on whether I have seen that myself, but I think there is some credibility to the suggestion that life-threatening calls-cardiac arrests-are being responded to by EMTs, without a paramedic even having been dispatched.

Professor Willett: As a first responder, you will be aware that what matters is how quickly external cardiac compression commences. It is a matter of what resource you have available that is closest to achieve that first goal. Again, that is a very clinical, individual decision. Clearly, a paramedic would be the ideal, but, if a paramedic is further away than someone who can start compressions in the absence of someone like you, it would clearly be a sensible decision to send them. You will see multiple deployments. From your experience in the ambulance service, you will be aware that it will do whatever it can to get the right resource to the patient.

Q370Andrew Percy: That is where the 70% figure and how near we are to hitting that target is important. We hear a lot about numbers, but I think-

Professor Willett: What is the evidence base for 70%? What does that figure come from? We should be looking for the evidence for how we address the clinical needs of the patient in the position they are in at the time, as close as possible to where it is happening.

Earl Howe: On the response time targets, I would simply say that in the ambulance trusts I have spoken to-and I have also spoken to Anthony Marsh-it is not the targets that are causing most concern but the way in which services are being configured to meet those targets. Ambulance crews have said to me, "We are not in the right place at the right time. It is an organisational issue." They do not argue with the fact that timeliness is vital-quite the reverse-but they think that more could be done to make sure that the targets are met.

Chair: Sir Bruce?

Sir Bruce Keogh: I was going to ask your permission to talk on a different subject.

Chair: Okay.

Q371Andrew Percy: I want to ask just one more question, which is kind of related to this. There will be an opportunity potential through the new social care Bill that is coming forward. It relates to nursing homes. It is slightly off topic, but it is important, because we have heard that they are the source of a large number of calls to the ambulance service.

Why don’t we require their staff to be trained in cardiac arrest or for there to be a defibrillator in every nursing home in the country? It is a relatively inexpensive thing to do. Other countries and many US states, such as the state of Texas, now require it. Nursing homes, which are the source of a lot of cardiac arrest calls for the ambulance service, are not required to have that. Why not? Is that something we should be looking at? In the past, the Department seems to have been very anti it.

Earl Howe: The British Heart Foundation took charge of this some years ago. I recognise fully the value of defibrillators, and many were actually deployed in public places around the country. To compel a privately run care home, which is what many of them are, to do certain things would require a stipulation in the contract, if the care is commissioned by a local authority or, indeed, by the NHS.

Q372Andrew Percy: We compel them to have food handling qualifications for their staff.

Earl Howe: Yes, we do.

Q373Rosie Cooper: Would it be cheaper to give them one?

Earl Howe: It might be.

Q374Chair: It would not be cheaper. Whether you do it by giving them one or regulating them to do it at their own expense, surely the question is whether it is a sensible use of resource for patient interests.

Earl Howe: I think that is the issue-whether it is a sensible use of resources. The advice I have consistently had is that there is much more mileage to be gained in training people in first aid and in resuscitation skills.

Chair: Hopefully, there are one or two of those around in a care home.

Andrew Percy: Not always. That is the problem.

Earl Howe: No, not always.

Q375Andrew Percy: That is why I think the two should go together as a requirement.

Earl Howe: Indeed. We are seeing organisations such as the Red Cross and St John Ambulance doing excellent work on training people in first aid, but-

Andrew Percy: It strikes me that these people are making money out of providing a care service and that the very least they should be required to do is to have that potentially life-saving equipment and to have proper first aid training for their staff. We do not seem to do that like other parts of the world do.

Q376Charlotte Leslie: If you are going to organise swimming lessons and are going to use a pool, you have to have a medically qualified, fully-trained lifeguard on site. It seems extraordinary that we do not have the same in a care home.

Earl Howe: I agree with you. I think it is something that commissioners need to have at the front of their minds.

Q377Chair: I am not entertaining a distraction here, but it might be something for our friends in the Care Quality Commission.

Earl Howe: Quite possibly.

Sir Bruce Keogh: They are coming soon, aren’t they?

Chair: Indeed.

Earl Howe: It is the CQC’s job when it goes into a care home to look at whether the skills that are there are appropriate to the patient mix and the residents who are in the care home.

Andrew Percy: It was a little off topic-I apologise.

Q378Chair: Sir Bruce wanted to say something.

Sir Bruce Keogh: I would really like to ask for the Committee’s help. If anything has become clear in the course of these discussions, if it was not clear before, it is that this is really complex. We are stuck in a set of new structures and new relationships that are pretty immature in many senses. Those relationships have not matured, and we are working in a much more devolved environment than the NHS has ever experienced before. There are those who believe in the innovation that will come out of that devolution and those who fear it. Nowhere is this seen more than in the area of urgent and emergency care, which is really the bit of the NHS that in many senses people value the most. We are dealing with strong views and concerns about centralisation over localisation.

To improve this system, we have to get better alignment between primary care, out-of-hours services and ambulances, which are grossly underused in my view. We have to understand how the accident and emergency front door, if you like, interrelates with the rest of the hospital. We have to work out how the back door relates to social care, community services, pharmacy and local government. We are trying to have this debate in the face of incomplete evidence; I think our submission to you on the evidence base shows that. We have to have it in the face of changing technology; simply the impact of the mobile phone on health will be very significant. We have the plethora of names Keith Willett alluded to-a sort of alphabet soup of places you can go to for help-and public concerns over 111. Finally, we have a whole lot of emotion around red-and-white signs and what they may or may not mean as the front door.

It would be really helpful to us, as we embark on trying to conduct our urgent and emergency care review, if you could, please, give some pretty serious deliberation to the evidence base that we have presented and help by asking parliamentary colleagues to have a look at it. We will, of course, do what we can to engage the public and the professions. When that is done, we will reassemble the evidence and adjust our principles accordingly. The difficulty is that we do not know where some of this will lead, because it is a very genuine evidence-based attempt to improve the service.

I suppose this is not a question you hear very often from a witness, but could we come back to the Committee when we have reassembled that and seek your scrutiny-I guess that is the best way of putting it-so that we can then take things back to NHS England to put the right system levers in place to make things work?

Q379Chair: You are certainly right to say that you are the first witness who has asked to come back. One thing all of us in the room are agreed on is the importance that patients attach to early, prompt access to high quality urgent and emergency services. The Committee is taking evidence on this and will produce its own report. Of course we would welcome the opportunity to pursue this subject further. We shall no doubt be required to do so, both by our constituents and by our own internal concerns about this service as we look forward.

Sir Bruce Keogh: I think it is an issue that is bigger than just the NHS. How we address this is really a massive societal issue.

Rosie Cooper: Sir Bruce, you have my absolute and utmost respect, but what I would suggest you do, when the transcript of this meeting comes out, is you just have a read of it. You will then hear why I, as somebody who has worked in and been part of the NHS for such a long time, just do not have the confidence that the evidence is there. I would not go to the front line for this.

That is really, really sad, because people depend on us to ensure that they are getting the right information. If you look at what is being said out there, nobody understands what has been going on in here today. I understand the direction of travel, but it is not underpinned by real evidence. We are not taking the people with us. I will say that, today, you have not taken me with you at all. That is a really sad place to start.

Chair: We will be here for some time if we have closing statements from everybody.

Andrew Percy: Nor should we rely just on anecdotes either; we need evidence.

Chair: Thank you, witnesses, for your patience with us this morning. No doubt we shall pursue the dialogue, as you suggest.

Prepared 23rd July 2013