§ Motion made, and Question proposed, That this House do now adjourn.—[Ms Bridget Prentice.]
9.54 pm§ Dr. Richard Taylor (Wyre Forest)I am amazed and delighted to have been able to hear the concord and unanimity of our previous debate, which was a delight, rather than the usual arguments that go from side to side of the House. I am also delighted that I shall not have to watch the clock and that I may be able to go on for a little longer than a quarter of an hour—
§ Mr. Deputy Speaker (Sir Alan Haselhurst)Order. It may help the hon. Gentleman to know that I shall have to interrupt him at 10 o'clock to put the Question again.
§ Dr. TaylorYou are very kind, Mr. Deputy Speaker. I have had that experience once before, so I shall sit down quickly when the time comes.
Unfortunately, I shall not be continuing the picture of concord, pleasure and happiness, as I am about to throw a large stone into that lovely tranquil pond. The effect on acute hospital services of the European working time directive can be likened to a time bomb. There is some warning so that people can begin to plan how to cope with it, which is why I am raising the subject. I am pleased to see the Under-Secretary of State for Health, the hon. Member for South Thanet (Dr. Ladyman), and hope to hear from him that the Government are taking that potential time bomb seriously and that they have some answers.
The problems are recognised by the professions, although not by the public; nor are they recognised by many MPs, given the staggering lack of attendance in the Chamber—unless that is due to my reputation for thoroughly boring oratory. I fear that if the time bomb is not defused it threatens to disrupt the Government's splendid intentions for updating the national health service and improving hospital services. I am purposely scaremongering, in the hope that I shall stimulate a response from the Minister that reassures me that my worries are somewhat in vain.
The threat from the working time directive is especially to acute services—accident and emergency departments, medical units, surgical units, acute orthopaedic units and obstetric units. The hours of junior doctors have, rightly, been cut. My first job—44 years ago—was half a mile from this place. I worked for one of the old-style consultants who expected all the castors on the beds in the ward to be pointing in the same direction. At any time of the day or night, he would summon his housemen to greet him in the hospital foyer. He expected them to work 24 hours a day, seven days a week, for six months at a time. Inevitably, housemen such as me cracked up halfway through, so I am wholly in favour of junior doctors being given a reasonable lifestyle.
I am delighted that over the past few years there have been progressive cuts in hours and improvements in pay. The onerous on-call rotas have been better paid. More recently, there have been limitations on hours. Those measures are essential in the interests of the health of junior doctors and of their family life. Most of all, they 640 are essential in the interests of patients because of the quality of care that junior doctors can give when they are reasonably rested.
However, there are already some grumblings from some junior doctors, especially junior surgeons, that they are not receiving enough hands-on experience—the surgical term is "not enough cutting". Under the working-time directive, there will be further restrictions on the hours of junior doctors: 58 hours a week soon, progressing slowly to 48 hours. However, the killer fact, as the Secretary of State for Health acknowledged last week at a meeting of the Select Committee, is that time on call, even if one is asleep, counts as time working and has to be included in that 58—ultimately 48—hours. There will be huge penalties if trusts do not manage to get down to those levels. Obviously, the effect is that we need more doctors of all grades very rapidly. That is impossible because of the speed with which—
§ It being Ten o'clock, the motion for the Adjournment of the House lapsed, without Question put.
§ Motion made, and Question proposed, That this House do now adjourn.—[Jim Fitzpatrick.]
§ Dr. TaylorThe major problem with the reduced hours is that on-call rotas become impossible and we have to move entirely to shift systems for junior doctors. Shifts are largely unpopular. Doctors do not come into the job to work shifts; they come in to get to know patients and to see them through the whole admission process and then perhaps to follow them up as outpatients. That becomes entirely impossible with the shift system, so continuity of care becomes a problem.
Doctors need absolutely excellent notes, and excellent hand-over and excellent communication between doctors and between nurses are needed. There has been a very sad recent example of that simply not happening. The Health Committee conducted an inquiry into Lord Laming's report on the Victoria Climbie tragedy. The communication between doctors, nurses and, indeed, hospitals handling that tragic case left so much to be desired that the importance of the continuation of care was underlined time and again. Not only do the notes have to be written and be legible, they have to be read by the people taking over. So shift systems are very difficult to make work.
I must mention the consultant. Life becomes impossible for the really conscientious consultant because he or she is aware that he or she is the only person providing continuity of care, as everyone else is on a shift system. Let us consider what that is like for patients. They arrive at hospital and are clerked in by a junior doctor. They unburden their soul and tell the doctor all about themselves, their illnesses and their secrets, but they never see that doctor again. That is demoralising not only for those patients, but for the doctor. To get round the problem, we obviously need more consultants a nd more junior doctors very rapidly. I fully support the Government's plans for more money, more doctors and more nurses, but we need them quickly. We have to be worried about vacancy figures for consultants because they contain certain inaccuracies.
I shall spend a few minutes talking about the views of those in some of the different specialties. Not very long ago, the Royal College of Physicians—my own 641 college—carried out a survey of 211 acute hospitals in England and Wales. It found that 166 of those hospitals were felt to have insufficient middle-grade doctors—specialist registrars—to give continuous 24-hour cover for acute medical admissions and 44 of them had fewer than five middle—grade doctors, and we do not know how they are coping at the moment.
§ Mr. Archie Norman (Tunbridge Wells)The hon. Gentleman is making an excellent speech. I agree with every word he has said and I congratulate him on raising what is, as he says, a very important subject. Does he agree that the greatest difficulties will be experienced by the smaller acute units that simply do not have the number of registrars and doctors to provide the necessary cover and that, if we proceed with haste in implementing the working time directive, some of those units will have to close?
§ Dr. TaylorThat point is well made, and I shall deal with—it I am not pulling any punches—by listing the hospitals that will soon be under threat.
The Royal College of Physicians is extraordinarily worried. The Royal College of Surgeons is also worried. It is concerned, too, about the abbreviated teaching that surgeons are now getting, and it is worried that if the training is hurried through even more, we will get newly appointed consultants who do not have as much experience as they ought to have.
The president of the Royal College of Obstetricians and Gynaecologists kindly wrote to me in July this year, saying that
there are currently insufficient junior doctors to provide adequate levels of service cover on wards and there will not be enough qualified doctors to fill vacant consultant posts in the near future.That is without taking into account the working time directive, if it is to be fully enforced. For the obstetricians, the situation is compounded by a tremendous shortage of midwives, and one sees little chance of that being improved. The obstetricians are also worried about the adverse impact on training. The move for obstetricians and gynaecologists to be either gynaecologists or obstetricians will compound the problem again, because twice as many are needed if they are not doing both jobs.The anaesthetists perhaps present the starkest problem. It is already a shortage specialty, and I have heard a claim that to meet NHS targets and comply with the working time directive from the anaesthetic point of view, every graduate from every medical school for the next five years would have to become an anaesthetist.
Lastly, accident and emergency is the bread and butter and is most important to all our constituents. It depends on all the other specialties being there, and it also depends on rotas, which will be extraordinarily difficult to meet. That raises the question, as the hon. Member for Tunbridge Wells (Mr. Norman) mentioned, of the viability of a number of hospitals, A and E departments and acute services. Where hospitals that are quite large are very close together, we must ask how much can survive at each of them. We think of Shrewsbury and Telford, Ormskirk. and Southport, 642 Wakefield and Pontefract, Cheltenham and Gloucester, and Hartlepool, which is very near Stockton and Middlesbrough. In relation to smaller acute hospitals, we must look at Bassetlaw, Grantham, Horton hospital in Banbury, Weston-super-Mare, Halton general in R uncorn, Hexham, Montagu hospital in Mexborough, Bridlington, Newark, Clacton, Louth—I could go on. The list is very long.
What is the Government's role? First, it is to admit the potential crisis. I was delighted that the Secretary of State said to the Health Committee that the working time directive—particularly the effect of being on-call counting as work, even when one is asleep—was a killer. A glimpse of recognition is therefore coming through. The solution must bear in mind the patient as well as the staff. It must steer between safety, what is financially possible, access and conflicting advice. On the one side are the militant junior members of the British Medical Association saying, "Get on with it. We can't wait for it." On the other, the more sane and sober royal colleges are injecting an air of realism, saying, "For goodness' sake, please give us more time. We know you are putting in more doctors, and you are putting in the money, but it must have time to filter through."
The Government have made a start in addressing the problem with the splendid document, "Keeping the NHS Local—A New Direction of Travel", which came out in February. It emphasises the importance of local services to local people. I am sure that you, Mr. Deputy Speaker, will realise that I would not be here at all if wholesale downgrading against local people's wishes was a viable possibility.
In my neck of the woods, we have shown absolutely that we cannot replace a full A and E department serving 135,000 people who live close by with a minor injuries unit without a doctor, and expect those needing to see a doctor in an emergency to go 14 to 35 miles without overloading other A and E departments and the ambulance service and without dire social consequences.
Only last week, I received a letter from an 88-year-old lady who had been taken to hospital in an emergency after she had suffered a minor collapse. She was taken 18 miles away and her two elderly friends of 90 and 91 went with her. She did not need admitting to hospital; she only needed to hear a doctor say that she was all right. However, she ended up 18 miles away from home and the only way to return was by taxi. These three elderly ladies, of whom two are partially sighted, had to find a taxi and rake out their handbags when they got home to find the £46 to pay. That is absolutely unacceptable.
The answer must be to provide if not all full A and E departments, acceptable local emergency centres that will keep most local people within their area. That is essential for my constituents as well as for those who go to the small local hospitals, which will almost inevitably have to be reconfigured in some way or another. I hope that the Minister will explain how the Government will solve the problem by taking into account the needs of patients and staff.
I finish with some comments from the Royal College of Physicians specialist registrar adviser, who forecasts two possible scenarios. If the Government press ahead with full implementation of the working time directive, he says that the consequences may be catastrophic.
643 However, the Government could be forced politically by umpteen threatened closures to accept at the eleventh hour that postponement is inevitable. I conclude with a quote from the same specialist registrar adviser. He says:
Ultimately, there may be a difficult choice between compliance with bad European law and the maintenance of safe levels of care.
§ The Parliamentary Under-Secretary of State for Health (Dr. Stephen Ladyman)I congratulate the hon. Member for Wyre Forest (Dr. Taylor) on obtaining this debate and on his continued interest in an important issue about which he has strong views.
I assure the hon. Gentleman that we do not in any way underestimate the impact of the working time directive on the NHS. I am not sure that I would liken it to a time bomb, but it certainly represents a huge challenge. Recent judgments by the European Court of Justice have complicated matters further, and the hon. Gentleman asks us whether we are prepared for the implementation of the directive by August 2004. Let me make it clear that we have put in place a considerable and extensive work programme designed to help and support the NHS with its implementation. That said, it is unrealistic and wrong to expect the Department of Health to micro-manage compliance. As the hon. Gentleman implied, thorough local planning for the working time directive is crucial to achieving compliance.
For that reason, we have instructed strategic health authorities to monitor progress in every trust. In turn, we are working closely with SHAs in particular on those issues where national solutions or actions are needed. All trusts have been asked to provide SHAs by the middle of this month with a summary of their plans to achieve compliance. They have also been asked to provide fully detailed action plans by 31 December this year to facilitate national solutions where appropriate. Nationally, we are picking up on reports from SHAs and many pilot sites and other projects, and we are already working hard to help spread good practice from the pilots and provide tools to help with implementation, as well as taking direct action on national issues.
Implementing the working time directive requires examining the quality of service that we provide to patients and improving the working lives of doctors in training. Tired doctors and long hours are not acceptable in this day and age. The directive is not unwelcome. It is a sensible reform that could improve the health and safety and working lives of all employees in the NHS.
The recent judgments of the European Court of Justice have changed our understanding of what is meant by working time and made it much more difficult to comply with the requirements of the working time directive for doctors in training. There are particular questions about whether time spent asleep but on call should count as working time and trigger an entitlement to compensatory rest, and how soon such rest should be taken. We have registered our concern with the European Commission about the impact of those judgments. Other countries have joined us in expressing their concerns and we shall continue to press the case for 644 a revision of the directive to deal with the problems raised. However, let me stress that the deadline of 1 August 2004 remains in place and it is important that we work towards it.
On the other hand, we should not be too pessimistic about our ability to meet the requirements of the directive for doctors in training. We have achieved much over recent years through the new deal initiative and I think that we can claim already to have made significant progress in reducing the hours that junior doctors work. I am pleased that the hon. Gentleman recognised that progress.
Our latest national monitoring exercise, which was carried out earlier this year and validated by junior doctors themselves, indicated that, as a result of new deal, almost 90 per cent. of all junior doctors were working fewer than 56 hours per week and almost 80 per cent. of junior doctors met both the 56-hour limit and the new deal rest requirement. However, I accept that we need to go further. Reducing the hours that doctors in training work will involve changing the way in which we organise and provide many of our services, especially at night and weekends. It will also require changes to how we employ many of our staff and the way in which they work. It is for that reason that several national pilot sites are testing new ways of providing services so that we can learn lessons from their experience.
To facilitate that further, we are working with the Academy of Medical Royal Colleges under the terms of a memorandum of understanding. In addition, we are working with individual medical royal colleges, the joint consultants committee of the British Medical Association, the Royal College of Nursing and other key stakeholders through regular meetings to consider issues for which national solutions are needed. Let us be clear that this is not only a junior doctor issue. It is about different and better ways of working throughout all professional groups in the NHS. The potential contributions of nurses, midwives, therapists, pharmacists and support workers, as well as doctors, are critical to the redesign of services. Redesign is one of the key tools to help to achieve a reduction in the hours that doctors in training work, and it has the potential to provide new ways of delivering services that avoid the need for reconfiguration.
§ Mr. NormanDoes the Minister accept that the case made by the hon. Member for Wyre Forest (Dr. Taylor) and many others. including the Royal College of Physicians and the BMA, is not that the working time directive is a bad idea of itself but that the NHS is simply not prepared for its implementation? It is common sense to say that there is every case for deferring implementation so that hospitals, and especially smaller units, are allowed more time to prepare for it. If the Minister does not accept that, will he guarantee that not one single acute bed will be lost and that not one single acute unit will close at night as a consequence of implementation in August 2004?
§ Dr. LadymanThe guarantee of not losing a single bed or a single service is unreasonable. Services will certainly change. However, it would be our objective to strive to meet that guarantee. I expect to give the hon. Gentleman an idea of how we intend to achieve that and I hope that he will be in a better position to judge whether the NHS will be prepared in time.
645 As I said, the issue is not simply about junior doctors: it is about different and better ways of working across all professional groups, and redesigning services so that we do not need to reconfigure them. That means approaching planning for reducing the hours that doctors in training work from a different perspective, especially in dealing with acute services out of hours. Our hospital at night pilot sites are developing some interesting models. For example, rather than maintaining multiple rotas across all the specialties at night, a single, multidisciplinary team is put together to cover the whole hospital, or at least a large part of it, for the out-of-hours period. The composition of the team is determined by analysing what actually happens during the out-of-hours period and, from that, defining what skills are needed within the team to ensure safe, high-quality services at all times. That is the sort of reconfiguration and redesign of working practice of which the hon. Member for Tunbridge Wells (Mr. Norman) is no doubt aware from his experiences outside the House. It shows the effort that we need to make in the NHS.
In respect of maternity services and the care of the new born, paediatrics and obstetrics are two acute specialties that do not easily lend themselves to cross-cover. We are funding national pilot sites concerned specifically with those services. We recognise that they require particular and different solutions from those needed for general acute services. I am delighted that Professor Bill Dunlop, president of the Royal College of Obstetricians and Gynaecologists and chairman of the joint consultants committee, is chairing a working party to consider the issues and possible solutions further.
Some solutions that we are considering specifically to keep services local include increasing the supply of staff and exploring skill-mix, but that will, of course, need to be considered in light of the national service framework for children, which will cover maternity services. Other options available for consideration will include innovative models of maternal and neonatal care, including the scope for extending midwife-led care and the potential for midwives to enhance their roles. The Department has also invested centrally in the growth of both paediatrics and obstetrics and gynaecology specialties. As a result, the number of trainees increased by about 27 per cent. for paediatrics and 10 per cent. for obstetrics and gynaecology between 1997 and 2002.
So far as smaller hospitals are concerned, reconfiguration and implementation of the directive need not mean closure of local hospitals. When combined with the potential of redesign, and considering the whole health system in the locality, models of care can be developed that enable all the hospitals in an area to work together to provide the full range of services for local people. There will need to be significant changes to ways of working, including much greater use of non-medical practitioners and increasing use of emergency teams to provide cover at night. That is why we are encouraging and funding the piloting of innovative service delivery models that have the potential to improve sustainability of services, especially in smaller hospitals. That includes working with health systems to plan change and build on the evidence base to support the concepts and service models described in 646 "Keeping the NHS Local—A New Direction of Travel", which I was delighted to hear the hon. Member for Wyre Forest describe as a splendid document.
Importantly, that strategy means that the NHS needs to develop options for change with, rather than for, patients and local people, another point made by the hon. Gentleman. That does not mean, however, that local hospitals will never change. There will be times when there is strong evidence to support the centralisation of some specialised care into larger centres to give patients the best possible outcomes. Equally, there will be opportunities to move services out of larger centres into more local settings. That is another reason why I cannot give the hon. Member for Tunbridge Wells the guarantee that he sought because there will be times when it is inevitable that services change.
Our focus is on redesign rather than relocation. Redesigning services extends the options for meeting local needs and expectations. The NHS needs to exploit the contributions of different hospitals and primary, intermediate and social care providers. They need to work in partnership, with genuine integration and joint planning of services. The strategic health authorities are also overseeing that work. In very simple terms, the key to planning for compliance can be described as the three R's: rotas, roles and redesigned services. Many parts of the NHS are already putting that planning into effect.
As well as the hospital at night pilots we have 10 working time directive pilot projects up and running, testing new approaches to service delivery and showing how effective new roles for staff and new ways of working can be. Some of those pilots are looking at doctors' rotas. They are testing the benefits of consultants working at night and of senior house officers cross-covering between medicine and surgery or medicine and accident and emergency. They are testing shift systems for doctors, and rotas that combine SHOs with other practitioners at night and out of hours. Those changes can be challenging, but they can also be rewarding.
Other pilots are testing changes to the traditional roles of non-medical practitioners; there are new roles for nurse practitioners on call to the wards at night. In another pilot, theatre technicians have been given the opportunity to train to work in resuscitation teams. One of the pilots is developing new, non-medical roles in anaesthesia in several trusts around the country, supported by the Modernisation Agency's changing work force programme. In another pilot, nurses, operating department technicians and a physiotherapist are training together as peri-operative specialist practitioners to take on the complete care of patients before and after operations.
Overall, our strategy for reducing the hours that junior doctors in training work is a multi-faceted challenge and one that is underpinned by the safety of patients. Although it is individual NHS trusts that have to find the right solutions for their local circumstances, they can do that only with the right support from their strategic health authorities, from professional organisations and from the Department of Health. So I am pleased to be able to tell the House that all those organisations are indeed working closely together at 647 national level to ensure that the quality of service is maintained and, where possible, improved during implementation of the directive.
I recognise that more must be done to reduce working hours, and that will inevitably mean further investment to support the changes that will be necessary. We have already allocated over £21 million this year to the NHS to prepare for the directive's implementation. Of that, over £7 million has supported the working time directive and hospital at night pilot projects, and a further £12 million is going to SHAs to provide further local support.
Clearly, if we are to succeed in reducing the hours that junior doctors work there will be a need for more doctors, although that is not, and cannot be, the only solution. It is important also that trusts demonstrate that they have considered all the options and not gone straight for the more and more doctors scenario. We must use this opportunity to move away from outdated working practices that are not helpful to doctors in training or, more importantly, the quality of patient care.
On that point, I am proud to say that we have increased significantly the number of consultants in post: their numbers have risen by nearly 7,000 since 1997, an increase of 32 per cent. We will increase the numbers of consultants and GPs by a further 15,000 by 2008 over the 2001 figure. The hon. Member for Wyre Forest acknowledged what we have achieved so far, but said that he wanted the doctors to become available more quickly. We want that too, but they do not grow on trees, and they take time to train. We are producing them as rapidly as we can.
In addition, we have achieved our target of a further 1,000 specialist registrars 18 months ahead of schedule, and that growth is continuing. In 2003–04, we are distributing central funding for the implementation of 400 more training opportunities and we have also given trusts scope to create up to 1,500 additional specialist registrar opportunities through local funding. We have made it clear that those training opportunities should be implemented in a way that supports compliance.
648 As I stressed earlier, we have made it clear that SHAs must ensure that every trust prepares a fully detailed action plan to achieve compliance. The strategy for achieving that may include additional specialist registrar posts, and opportunities to fund additional posts locally should be targeted to support that. If further national training numbers are needed to support compliance, they will be released on the completion of plans signed off by SHAs in collaboration with postgraduate deaneries.
We must be clear that increases in training numbers should not be a substitute for changing working practices; it is not possible to comply with the directive solely by increasing the number of specialist registrars. To target the limited resource of additional doctors most effectively, it is essential that plans are quality-assured and produced through a robust process, including consultation with neighbouring work force development confederations and postgraduate deaneries where necessary.
Trusts already have the scope to convert SHO posts to specialist registrar posts—up to 700 in surgical specialties and up to 600 in other specialties. WDCs and postgraduate deans are currently working with trusts on SHO conversions, and that should be explored as a strategy to help to achieve compliance, linked to a review of the level of cover needed at different times of the day and night.
In 2003–04, we are distributing central funding for the implementation of 400 more training opportunities, and we have also given trusts scope to create up to 1,500 additional specialist registrar opportunities through local funding. Postgraduate deans are giving priority to hospitals facing working-time directive challenges when considering—
§ The motion having been made at Ten o' clock, and the debate having continued for half an hour, MR. DEPUTY SPEAKER adjourned the House, without Question put, pursuant to the Standing Order.
§ Adjourned at half-past Ten o'clock.