HC Deb 11 May 2004 vol 421 cc61-8WH 4.14 pm
Dr. Richard Taylor (Wyre Forest) (Ind)

I start with a profound sense of relief, because I had thought that I was the only Member to have such Adjournment debates with just a Minister present. I have just seen another hon. Member having a one-to-one debate, so I am delighted.

I thank the Minister for attending a second debate. I know that he knows a lot about the west midlands and about my patch in particular. I can reassure him that I will talk about my patch only in passing and will mainly talk about ways in which I think that the NHS can be helped overall.

Despite the vast amount of money that the Government are quite correctly putting into the NHS, there are tremendous challenges to be met in the new ways of working. One of the crucial debates that must take place is that of safety versus access. To my constituents and to others throughout the country, access means proximity to services. It is easy, from the medical point of view, to say that safety has to be the number one priority, as it is in the interests of the patients, and there are inevitably fears of litigation. However, it is arguably not quite a definite winner for the patient. There are pros and cons both ways. Safety is important, but there have to be slight compromises on occasion because proximity to certain services is crucial for some groups of people. I am not arguing that access to everything for everybody is possible, and I never have. Obviously that is not possible.

There were a lot of misconceptions about why I stood for Parliament and the campaign that I headed. People often thought that we were fighting to keep everything, which was never the case. We accepted from the beginning that high-powered things were done better where they were done more often particularly things such as vascular surgery. Patients are perfectly prepared to travel for the high-powered services, complicated elective work, complex cardiac work and complex specialist cancer services. They are used to seeing helicopters taking families to major trauma centres for major accidents and major burns. However for absolutely straightforward bread-and-butter emergencies, access—meaning proximity—is essential.

This debate is about managed clinical networks. I believe that if they are properly instituted and agreed to by all partners, such networks could answer the problem in terms of safety and proximity. The networks came to prominence in 1998, with the acute services review in Scotland undertaken by the Scotland Office for the Department of Health. In Scotland there are obviously large areas with sparse population, so problems of access and proximity are particularly bad. However, the lessons learnt from that review could also be drawn to this country. I have a couple of quotes from the report: As an alternative to the 'hub and spoke' model, some of the networking systems described to the Review feature the sharing of patients, expertise and resources, rather than unidirectional centripetal flow. "Sharing" and "partnership" are the crucial words. The report also states that the critical mass needed to achieve the benefits which might flow from increased volume of activity can come through managed clinical networks rather than the centralisation or concentration of services. That addresses the issue of safety. Although those points were made so powerfully in Scotland in 1998, there are fears that centralisation is occurring and that even in Scotland managed clinical networks are becoming a bit of a euphemism.

Turning to England, networks are obviously well established for complicated matters, such as cardiac surgery, cancer services and diabetes. I wonder whether it is a coincidence that those three all have national service frameworks. Networks for such matters are absolutely essential and valuable. As I have said, a full range of services cannot be provided everywhere and citizens accept the need to travel. They welcome going to the best place and patients with a rare cancer will travel for miles to go to the right place.

We need a network in accident and emergency departments more than anywhere. People need that service close to home; I am talking about the common, bread-and-butter emergencies, such as those that happen without warning, and for which nobody can make plans. The kids might be at school, or one could be elderly. One might be taken away suddenly or from one's partner and unable to let anybody know. Not everybody has a car or a mobile phone to let people know what is happening. Just closing an accident and emergency department and substituting it with a minor injuries unit is not acceptable to local people. That is what propelled me to this place.

I am looking not back, but forward; to the Minister's relief. I am considering how to avoid the same situation elsewhere and how to improve the situation for my friends at home, because it is eminently possible to do so. I realise, before the Minister tells me, that he has no power to make things happen locally, although I am glad about that. In 1998, the Government had no power to dictate what happened locally and, if the Government's overview and scrutiny committees had been in place, theHealth Service Journal wrote recently that the same events would not have occurred in Kidderminster.

Returning to accident and emergency networks, how will they help local situations and above all, how will they help the Government politically? What should they be like? As I have said, a network is a partnership and a sharing. In accident and emergency, it is a sharing of the district general hospital's all-singing all-dancing accident and emergency department with its outlying minor injuries units, particularly those in downgraded DGHs such as that in Kidderminster. That network shares patients, expertise and resources between the A and E department and the minor injuries unit. It will widen the range of patients that the minor injuries unit can see, and lessen unnecessary trips to the A and E department, so lightening its work. I raised the matter last week in health questions and the Minister of State, Department of Health, the hon. Member for Doncaster, Central (Ms Winterton) agreed that networks in A and E could be helpful. She mentioned emergency service collaboratives and emergency care networks, and I welcome the Minister's comments today about those because I have a feeling that such collaborative and networks do not involve local minor injuries units, as they should.

I have quoted Andy Black's work before, but I am going to do so again because it is so important. He is a well respected health service management consultant, who recently wrote in aBritish Medical Journal leader: If the price of moving the complex emergency to an appropriate centre of expertise is that this patient is accompanied by another nine or ten patients who are not complex acute cases, then another set of problems is launched. We have seen all too clearly the social problems of suddenly uprooting somebody and taking them 18 miles away, and the financial problems that they have finding their own way home at bank holidays or at weekends. In the same leader, Andy Black also asks how 'managed clinical networks' could be introduced so that local emergency units can flourish while complex emergency cases can be swiftly funnelled towards the appropriate specialist centres. There are more details of his ideas in the Nuffield Trust paper, "Local Medical Emergency Units", published in 2000.

The key is to share and rotate medical and nursing staff between such units. In the old days, when a minor unit referred a case to a major unit, the major unit thought nothing of the minor unit and would repeat everything that had been done. What a waste of time! In Worcestershire, there is no doctor in the minor injuries unit at Kidderminster, so everything that could conceivably require a medical opinion has to go 18 miles away. Time after time, the patients who go there are discharged as soon as they are seen and they have the problem of getting home.

Consultants in Worcestershire currently do outpatient clinics at the Kidderminster minor injuries unit, but they do not see any emergency patients. The sharing of a doctor on a network for back-up to the nurse practitioners would make a huge difference and would widen the scope of patients that the ambulances could take. Even the medical director at the treatment centre now agrees that we need a doctor in the minor injuries unit.

A true partnership, which is a network and two units sharing services and patients, could increase the range. It would fit with the Government's paper "Keeping the NHS Local—A New Direction of Travel" which states that the objective is to provide as a minimum a 'first port of call' (a service able to receive and provide assessment, initial treatment and transfer where necessary)". I appeal to the Minister to see the logic of this case nationwide and to support the need for a trial of such an A and E unit working in partnership with the minor injury unit to pilot staff reaction. Would they accept it? What about stress levels and waiting times? Would a widened ambulance protocol be possible? Would it reduce trips to the major centre?

It would be subtly different from the trials already ongoing in "Keeping the NHS Local" at Penzance, Bishop Auckland and Downpatrick because it would fill a gap lower on the scale to any of those. If it were suggested as a pilot at Kidderminster, it would be welcomed with open arms. This could provide an opportunity for the Government to show that if a local hospital that is under threat is downgraded, there is an outcome a bit less severe than what happened at Kidderminster in 2000. This could help the Government to take the politics out of it.

I quote again from "Keeping the NHS Local": Making greater use of networking between community minor injuries units and acute centres and other redesign approaches will be needed to ensure that people have locally accessible emergency care. I have 72,000 constituents who, together with about 70,000 neighbouring constituents, do not have locally accessible emergency care. I will battle until they do. This pilot trial would give an opportunity for the whole NHS to see that something like this could work to allay the anxieties of people in Hartlepool and Banbury and several other places that I could list at length. I will not do so.

4.28 pm
The Parliamentary Under-Secretary of State for Health (Dr. Stephen Ladyman)

As you said, Mr. Deputy Speaker, this is my second run-out of the day, the second of four this week. I am not complaining—I do not want the Prime Minister to think that I need any relief from my duties—but it means that I get a fairly eclectic choice of subjects to which to respond. I am grateful to the hon. Member for Wyre Forest (Dr. Taylor) for calling the debate and for putting his ideas on the record. He is right: most of these debates tend to be one to one, but I thought that that was something I was doing rather than the fact that he was involved. All my debates seem to be carried out on a one-to-one basis. If we do not get big audiences, at least we get top quality contributions.

The hon. Gentleman talked about proximity and safety. I agree that both have to be taken into consideration. I just wish—I do not criticise him for this because he has just taken an objective view—that there was more objectivity in discussing this. In my experience—my constituency in east Kent has gone through a painful reconfiguration—clinicians are devotedly attached to the notion of centralisation until decisions about reconfiguration are taken and they feel that their hospital is likely to come out of it worse than they thought, whereupon they immediately become converts to the idea of managed networks and distributed systems that allow far more centres to remain open.

I wish we could generate a more objective and considered debate on the matter, and understand the nuances and difficulties of balancing proximity and safety. The Government published "Keeping the NHS Local—a New Direction of Travel" to try to provide that additional guidance.

Dr. Taylor

This is exactly where the Government fit in. The professions are clamouring for patients to be made to understand the need for changes that are perhaps for the benefit of the professions. The Government must somehow engage with the professions to convince them that there are other ways of doing things.

Dr. Ladyman

I take the hon. Gentleman's point. By publishing "Keeping the NHS Local", we were trying to start that debate. In these days of "Shifting the Balance of Power", it is not for me to devise pilot studies that might meet local needs and balance proximity and clinical safety, but for clinicians, the primary care trusts and the acute trusts that serve the hon. Gentleman's constituency to come up with ideas. The Government—certainly this Minister—would not be interfering if they came up with something that they felt gave a better balance of access to services, while maintaining the necessary levels of safety. I encourage the hon. Gentleman to ensure that clinicians, managers and planners in his local area are aware of his ideas and engage with him in the objective debate that he is trying to stimulate now.

The hon. Gentleman has given me the opportunity to talk about how we are transforming accident and emergency services throughout the country and I shall not miss that opportunity. A little over a year ago, only about three quarters of A and E patients were admitted, transferred or discharged within the national health service target time of four hours. In March, that had risen to 94 per cent., and most patients are dealt with well within four hours. In human terms, that means thousands more patients getting faster treatment every day; at this rate, by next year we will be able to claim a standard of accident and emergency performance that no other country in the world will offer to its entire population. That is a major transformation, which requires the sort of difficult decisions to which the hon. Gentleman referred. It also requires us to have incentives in the system and to stimulate people to take the necessary decisions. Within the last few weeks, 87 acute trusts—more than half the total—received £100,000 each to recognise their outstanding progress in accident and emergency; trusts that did not qualify for the first payment are getting tailored support and trusts that continue to improve can earn £500,000 by this time next year.

If anyone objects to my focusing on total time performance, I can tell them that the clear message from patients is that that is what matters most to them. It is not the only thing that matters, which is why we appointed the first national accident and emergency patients' champion and offered every modern matron in A and E £10,000 to improve their patients' overall experience. All of that is making a difference and time and again front-line staff tell me that the atmosphere of accident and emergency has changed for the better. That would not have happened without the Government's determination to drive up the performance of accident and emergency, without our taking tough decisions and without the investment that we pumped into the health service, nor would it have happened without the dedication and hard work of front-line health service staff.

The transformation could not have been achieved without the sort of co-operation and networking that the hon. Gentleman recognises is essential. The Government recognised the importance of networks at the beginning of the process; alter we published our strategy "Reforming Emergency Care" in 2001, we made extra resources available specifically to fund emergency-care led staff in every trust and to establish local emergency care networks. All emergency care networks should have four fundamental objectives. First, to create a partnership between all the health and social care organisations within a geographical area; secondly, to break down artificial boundaries between services to help patients to gain access to better care; thirdly, to establish agreed shared objectives and shared responsibility for meeting those objectives; and, fourthly, to ensure that initiatives and developments spread throughout the system and produce system-wide improvements. As the hon. Gentleman knows, there is a Worcestershire emergency care network, which is chaired by the acute hospitals trust chief executive and meets regularly.

One reason why networks are important is that patients now have more options for unscheduled care than ever before, especially for relatively minor illnesses or injuries. As well as using A and E or the ambulance service, people can use their GP, NHS Direct, pharmacists, minor injuries units and NHS walk-in centres. Those are all popular with patients and are vital components of networks. The minor injuries unit at Kidderminster hospital is considered to be one of the most successful of its type and is used by 20,000 patients a year, three quarters of the number of people who used to go to the A and E department there. I was immensely impressed by the department when I visited recently. The nurses at Kidderminster hospital have telemedicine links to consultants at Worcester and Redditch.

Dr. Taylor

I would argue with the Minister about those figures. The last figure for people attending Kidderminster A and E department, when it was in existence, was about 43,000, whereas the numbers of people attending in Redditch and Worcester, in the same county, was 44,000 and 45,000 respectively—almost equal. The figure of 20,000 for the MIU does not give quite the proportion that the Minister suggested.

Dr. Ladyman

The figures that I have are from the local trust, but I shall certainly check them, and I undertake to write to the hon. Gentleman. If I have misled him, I apologise, but I believe that the figures that I have been given are accurate.

I was making a point about telemedicine links to consultants at Worcester and Redditch. The evidence shows that, as the MIU has developed and the nurses' confidence has grown, reliance on the link has greatly diminished. Meanwhile, I understand that the MIU has been treating all its patients within four hours and 70 per cent. of them within one hour.[Interruption.]

Mr. Deputy Speaker

Order. Is the Minister going to be a lot longer? I see that a Division has been called in the House. If he is going to be more than a couple of minutes, I shall have to suspend the sitting. Is that the case?

Dr. Ladyman

I fear so.

4.36 pm

Sitting suspended for a Division in the House.

4.47 pm

On resuming—

Dr. Ladyman

Before the Division, I was saying that the MIU in Kidderminster treats all its patients within four hours, and 70 per cent. of them within one hour. The trust has launched a number of initiatives to improve the performance of its accident and emergency department, including an integrated health and social care discharge team. It is important that patients understand that positive options such MIUs are available to them, which is why the Department of Health has organised several communication exercises better to inform patients about their choices for treatment. There are also numerous local campaigns.

Networks are not just about where patients receive treatment. The behind-the-scenes co-operation is just as important, as that determines the quality of service that patients get. That means that there should be good teamwork within acute trusts, and that acute trusts should work closely with ambulance trusts, primary care trusts and social services.

The hon. Gentleman spoke about the importance of managed networks. It is certainly true that they have been a success in other fields, but what matters most is that emergency care networks are effective, not how they are managed. All networks are led or managed in one way or another, but our approach has been to encourage and facilitate, not to dictate from the centre. We want to allow local networks to meet local needs. If trusts are to meet the NHS plan target by the end of the year, and we are determined that they will, they will need effective networks. We encourage and facilitate, and we have made available resources to set up networks. We have published guidance, which is now being updated and amplified, and will be reissued shortly.

I also mentioned the incentive scheme for accident and emergency departments' performance, which recognises the pivotal role of networks. Acute trusts can qualify for up to £500,000, but ambulance trusts that improve their performance can also qualify for significant monthly payments. Mental health trusts that improve their 24-hour crisis services can get £200,000, and primary care trusts that plan and deliver high quality out-of-hours services will get £100,000.

We do not accept that there are any obstacles to effective networks that cannot be overcome by committed, motivated and local clinicians and managers who are supported by sound advice. Taken together, the imperative to reach the accident and emergency target, the financial incentives and the new guidance are a powerful encouragement to progress. There is also good practice for others to follow. For example, in Manchester, the ambulance trust and NHS Direct work together to provide a gateway for unscheduled care and to guide patients to the most appropriate treatment. In Essex, the ambulance trust no longer automatically takes its patients to accident and emergency, and it takes the lead in providing out-of-hours unscheduled care. In London, the ambulance trust has started to divert calls that clearly do not need an ambulance response to NHS Direct.

The hon. Gentleman has mentioned many times what he believes to be the potential effects of the European working time directive. We see the directive as an integral part of the modernisation of services that the NHS must plan for as it plans for all contingencies. Therefore, every trust has been asked to prepare an action plan for compliance. We believe not that services will close either solely or primarily as a result of the directive, but that networks will be vital to improving the level of services and to meeting the contingencies of the directive.

We are committed to maintaining local access to services, and we recently published guidance to that effect called "Keeping the NHS Local—A New Direction of Travel". We are not complacent, and we recognise that a small number of specialties, and certain types of organisation, face significant challenges. As well as providing direct support to individual trusts that are experiencing problems, we are funding 20 pilot projects and four "hospital at night" projects, which test approaches to achieving compliance with the directive, and develop ways of helping people to work better in partnership.

On top of that, the NHS Modernisation Agency has been running trials and pilot projects considering ways to free doctors' time, rearrange traditional rotas to support accident and emergency departments for 24 hours a day, and develop other new ways of working.

It is fair to say that the hon. Gentleman and I share some common ground, although we do not agree on everything. He will always press for more services to be delivered through the Kidderminster site, and no doubt the local NHS will want to accommodate him, subject to clinical safety and quality, and the local priorities that it sets. I reiterate my opening remarks, in which I encouraged the hon. Gentleman to talk to the local NHS about his ideas, which he is already doing. As I have shown, many of the ideas that he has highlighted are being tested and piloted in various parts of the country. If what he proposes is a good option for Kidderminster and is safe for his constituents, I have no doubt that the local NHS will want to explore it with him.

I assure the hon. Gentleman that the Government will continue to place a high priority on emergency care, and take a close interest in the development of effective networks and the way in which they can improve access to care and quality for all our citizens.

Question put and agreed to.

Adjourned accordingly at seven minutes to Five o'clock.