HC Deb 10 September 2003 vol 410 cc69-91WH

Motion made, and Question proposed, That the sitting be now adjourned.—[Charlotte Atkins.]

9.30 am
Dr. John Pugh (Southport)

Mr. Deputy Speaker—

Mr. Peter Atkinson (in the Chair)

Order. Before the hon. Gentleman begins his remarks, may I say that I am not a Deputy Speaker. I am simply the Chairman or Mr. Atkinson.

Dr. Pugh

Thank you, Mr. Atkinson. I apologise. I now see the name on the Table.

I have two cases to plead before the Minister—a specific case and a general theme. I am sure that other Members will want to describe their own parallel experiences and add their analysis to the debate. My objectives are quite specific, but I hope that the debate will range more widely than my speech does.

We all accept that accident and emergency departments, which we used to call casualty departments, are probably the most unpredictable and varied sector of modern medicine. They must be ready to field almost anything. They must deal with all ages, all ailments and all sorts of complaint, physical and mental, from the extraordinarily severe and life-threatening to the trivial and, at times, irritating. The key element of any accident and emergency department is that the patients go to it mainly because they require immediate attention and assurance. That is why the Government have stressed the importance of gauging waiting times in different facilities, and have set targets for them in their assessment of accident and emergency provision.

Although our attention is focused on targets, success must be measured to some degree by waiting times and other factors, such as a low rate of re-admission. We must assess the effectiveness of accident and emergency departments in some way. However, the unpredictability of accident and emergency—the fact that anything can happen—has led to several calls in the health service for increased training of staff, and for centralisation and the closure of small units that may be less competent at dealing with the full range of cases thrown at them.

Smaller units lack the full complement of specialists waiting in the wings, should something go amiss or happen out of the ordinary. However, centralisation comes with a price. Patients may have a longer journey, and may experience a delay in finding the reassurance that their problem is not out of control, or that it may not be as severe as they first thought. Centralisation increases social exclusion because more remote facilities mean longer transport journeys and more dependence on public transport, which may not be available. Not everyone has a fast and reliable car.

Statistics show that 75 per cent. to 80 per cent. of the through-put of A and E is standard, unsurprising medicine that is usually fielded well in any A and E department. Only about 1 per cent. of cases daily are extreme and life-threatening. However, physicians know that things can always go wrong, and I am sure that they would sooner treat patients wherever possible in omnicompetent, large A and E departments and accept the minimum risk, should things go wrong. In this age of medical litigation, one can understand their perspective. However, the vast majority of A and E clients have no need of such an omnicompetent A and E department and generally would rather have a more local facility.

There is a tension that the Government well recognise. That was evident in their recent document "Keeping the NHS Local: A New Direction of Travel", which says several important and encouraging things, such as: The mindset that 'biggest is best' … needs to change. It advocates a "closer to home" model, and discusses evidence that "small can work." It talks of helping local communities to "broaden their options," and it focuses on redesign rather than closure of facilities and relocation. Importantly, it speaks of implementing changes with people, not for them, and mentions "clinical networks" and "telemedicine links." It also discusses using imagination, thinking differently and involving the community.

I am sure that many people, particularly those with small local hospitals, found the document in many ways to be encouraging, thought-provoking and excellent. It gave comfort to many people who may have feared the total erosion of local services and the total domination of doctors' concerns.

I hate to use the words "producer interests". That is not my language for talking about public services, but I make the point that although doctors have the interests of patients in mind, they are also fully conversant with their own interests. For example, consultants would probably generally prefer that their patients travelled rather than they did because, by and large, they are busy people.

Other factors work against that document and the spirit of it. The agreement on junior doctors' hours constrains what hospitals and accident and emergency departments can do. When the working time directive kicks in, it will affect different specialisms differently. I understand that paediatrics will be affected less because a large number of paediatric specialists are female and have families to attend to, so they are currently unlikely to be working over the hours limit. The training standards and concepts of the royal colleges, which are raised all the time and justifiably so, also work against the document.

There is mixed evidence of differential clinical outcomes between smaller and larger units. Another pressure, to which it may be unkind to allude, is that NHS executives and others running NHS hospitals may gain more prestige from running larger units than a plethora of smaller ones. There is a balance to be struck, which the Minister and the Department of Health recognise. When that balance is wrong, the consequences are quite dramatic. There are scores of case histories to demonstrate that.

On 17 August, 3,000 of my constituents marched to the local hospital to present a local petition against changes in accident and emergency provision and other changes, which was signed by nearly 14,000 people. In my constituency, the community is at loggerheads with its major health provider. The local council's overview and scrutiny health committee is currently constructing a report in reaction to that, which I expect will soon be with the Minister. I do not think that it will be entirely comfortable reading for the hospital authorities, but it will provide a good deal of evidence, which the Minister might well like to consider.

In my constituency, there have been angry public meetings and scores of stories in the local papers, including poignant human stories about real people who have suffered real trauma precisely because of the confusion surrounding the way in which accident and emergency cases have been dealt with.

I will expand on the problem. We are now implementing the 1999 Shields report on reconfiguring local hospitals. In effect, it recommended a division of spoils between two hospitals, Southport hospital and Ormskirk hospital, which had been merged into one trust by the previous Government. The report concluded that maternity services, children's services and children's accident and emergency should be situated in the neighbouring town of Ormskirk, outside and away from my constituency, Southport. The traffic was not one-way. A number of facilities that were previously in Ormskirk were to come to Southport, including eventually, though not yet, accident and emergency services for adults. So the proposal was that adults go down one road to hospital, and children go in the reverse direction.

The one issue that has lit up public interest and incensed people most is children's A and E. In 1999, when the first proposal was made, I led the opposition to the changes. I am completely unrepentant about that. I said at the time that the myth of the ever-mobile patient and the static doctor was embodied in the proposals. I want to put on record that I am still opposed to the proposals, root and branch. In 1999, protest about the issue was mild, compared with the present situation. There are three reasons for that.

First, the original report recommended that Southport retain some in-patient paediatric provision. That was in the original report submitted by Professor Shields, but was removed by the then Minister of State, the right hon. Member for Southampton, Itchen (Mr. Denham). Secondly, the original report recommended that Southport A and E staff should have paediatric training. I am not sure that that has been implemented. Thirdly, there was a fatal ambiguity in the report as to what would happen to patients under the age of 16 who were self-referred, or referred by their parents, to Southport, as opposed to being taken by ambulance. There was much debate in 1999 about blue light ambulances rushing down the road from Southport to Ormskirk. That was contentious in itself, but there was an underlying supposition that if a parent turned up with their child at an accident and emergency department in Southport, the child would be treated.

I think that everybody recognised at the time that there would be problems. Southport and Ormskirk, for those who do not know, are linked by a winding and largely agricultural road, which is often blocked and suffers influxes of traffic at certain times because Southport is a holiday resort. A prime example would be last weekend, when there was an air show on Saturday and Sunday and it was simply impossible to move at any speed along the road. The case that I am making is not my own; it was embodied in the original Shields report. Shields explicitly recognised that in any reconfiguration of services, the road was an issue. I see that the hon. Member for West Lancashire (Mr. Pickthall) is in his place. He and I have worked hard to advance progress on the road and I would welcome anything the Minister might do.

Last time I initiated a debate on the subject, in December 2001, the then Under-Secretary of State, Department of Health, the hon. Member for Salford (Ms Blears) said: The hon. Gentleman's constituency has two good local hospitals but pretty poor road links. I understand that the proposal to upgrade the A570 is in fact the number two priority on Lancashire county council's transport plan, and I hope that even if it is not the top priority, being second will mean some action fairly soon."—[Official Report, Westminster Hall, 4 December 2001; Vol. 376, c. 66WH.] The action that the hon. Member for West Lancashire and I wish for is that, when the Lancashire transport plan is reviewed by another Department, there will be a wide acceptance that health should be a contributory issue in the progress of the development of that road.

I initiated a debate on the road link in 2001, and the Minister was reasonably bullish about what may be achieved to mitigate the problems. However, the problems have been compounded by insensitive implementation. That is the accusation that I am making—perhaps it should be called an allegation Perhaps the hospital authority would want to say something about it. I think that it would be widely agreed among informed people that the hospital has not done very well at implementing or defending the proposal on accident and emergency.

When the Minister receives the scrutiny and review report he will see evidence of very poor integration. By that I mean that there is little evidence that the ambulance service has been properly and thoroughly consulted and that the demands on it have been weighed, given that some people who previously would not have moved between hospitals will now be moved. There is some concern about the sudden increase in cases—particularly surgical cases—being received from Ormskirk at the neighbouring children's hospital, Alder Hey, often after being sent from Southport to Ormskirk. Many of my constituents have spoken of being turned away at Southport and sent to Ormskirk, and then being sent on to Alder Hey, because Ormskirk could not field the complaint. It is not only Southport residents who complain—rightly—about that. It would appear that Alder Hey is not delighted, either.

There has been no progress on the linkage between the hospitals, which was mentioned in response to my previous debate by the then Under-Secretary of State, Department of Health, the hon. Member for Salford. She talked about the development of telemedicine and the use of imagination. I have not seen a massive amount of telemedicine, and have found little in the way of imagination. We are dealing in this context, and perhaps in others, with a fundamentally confused set of protocols. In the present instance they relate to children's accident and emergency services, but I should not be surprised to find similar confusion in evidence elsewhere.

For the benefit of hon. Members who do not know about this, Southport district general hospital serves a community of well over 100,000 people. It is not a small cottage hospital. It is modern, highly equipped and purpose-built, and it has an A and E department, yet it offers nothing to parents and children. In fact, it has a sign repelling them. Worried, anxious parents with their children must, no matter what the complaint—unless it is so severe that the child must be stabilised in some way—leave their town, where there is a district general hospital and an accident and emergency department, and go to a currently unbuilt and partly understaffed facility in another town. I understand that elsewhere there are even longer journeys to get to A and E, but in some respects what I have outlined takes some beating.

I have asked the Minister whether he could think of parallel instances in other areas in which a fully-equipped A and E department includes no facility for children. I am not sure whether I asked the Minister who is present today, but I certainly asked the Department of Health to give me statistics about that, and I was told that they were not collected centrally, so I sent a researcher to spend a great deal of time phoning a range of hospitals. I found extremely few parallels—perhaps one or two. Many A and E departments had no paediatric unit, but none the less admitted children and dealt with children's complaints.

Chris Grayling (Epsom and Ewell)

The hon. Gentleman is raising some interesting points. In my constituency it was proposed three years ago to close the paediatric facilities at Epsom hospital, which would have led to the absurd situation of a parent who had been in a car crash with their child arriving at the A and E department and being admitted and kept in overnight, while the child could not be admitted. That was defeated by the weight of medical and public opinion—medical opinion in particular—so I suggest that the hon. Gentleman should involve local doctors in his campaign. I suspect that they may think that the state of affairs is very unsafe.

Dr. Pugh

The hon. Gentleman's intervention was extraordinarily helpful, but I can cap that story. In my neck of the woods, if a parent and child are in an accident halfway between Southport and Ormskirk, the child, in distress, will be taken to the accident and emergency department in Ormskirk, and the parent, because there will be no A and E, ultimately, in Ormskirk, will be taken to the one in Southport. That is the kind of incident that was cited in the debate on the Shields report, and I thought that it was bad enough, but things have evolved. The situation is, if anything, worse.

To answer the hon. Gentleman's point about medical opinion, having canvassed the GPs in the area, I found them divided on the changes, with the balance against. While it has not always been easy to assess medical opinion inside the hospital, I have not necessarily found every medical expert, including the royal colleges, agreeing with my side of the argument as unequivocally as I would wish. I think that they are wrong, but as I am not a medical practitioner, it is difficult for me to say why they are wrong.

I want hon. Members to imagine how it feels for an ordinary person, with a traumatised child, experiencing a major problem, to drive—it might not have been necessary to summon an ambulance—past a purpose-built A and E unit and on to another town. I also ask hon. Members to empathise with the situation that could occur in west Lancashire, where adults might find themselves in similar circumstances. In that area, there is at least the redeeming possibility of a minor injuries department. In Southport, there is nothing.

The system is not what was originally consulted on, it is not humane and it is not intelligible. It has hardly a defender in the town. The Minister might consider that I have already rehearsed the arguments presented by the royal colleges. However, even the royal colleges cannot defend the unintelligible, and the protocols at Southport A and E are unintelligible.

The situation is as follows, and I defy hon. Members to explain it clearly. The hospital authorities say that no child will be turned away—they are not as cruel as that—but that children who turn up will be triaged and only critical cases will be taken in, treated and stabilised. However, when they are asked why ailments that are standard but worrying for parents cannot be treated, they state that that is not within the competence of ordinary A and E staff, as such staff cannot adequately differentiate between minor, serious and critical cases and those that have to be dealt with immediately. That is a slur on ordinary A and E staff. They are said to know and not to know the difference between critical and non-critical childhood cases.

Although there are doctors present, the Minister, like me, is not a medical doctor. However, I know from his background that he will have more than a passing regard for logic, and the position adopted by Southport and Ormskirk NHS trust is incapable of clear expression. I refuse to accept the unintelligible, and I ask the Minister, who knows about seaside towns as well as logic, to think about the circumstances of families in Southport and of visitors to the town who, reporting to the local A and E department with their children because, for example, they have cut themselves on the beach, are told: "Hop it. Get over to Ormskirk."

Having been through such things before, I do not expect the Minister to wave a magic wand today. Nor do I expect him to rush into any sudden commitment. What I want is for the Minister to listen—not to me, as he has done that for long enough, but to my constituents, who are sensible, ordinary, non-political people, and to other hon. Members, whose constituents' case histories might parallel those of mine—and to help us to get the balance right.

We in Southport cannot sustain a situation in which a progressive health agenda is hijacked by a guerrilla war between the community and its hospital. There are better things for people to do than to row with their local hospital, and better things that can exist than a dispute between hospital doctors and their patients. There are signs that the local PCT and the local strategic health authority recognise that, and there are also signs that imagination may be stirring. All I ask the Minister to do is look, take counsel, review and, where possible, reverse those changes.

Broaching a general theme—I did say that I would talk about general issues as well as the specific issue—I conclude by drawing on a matter that has dogged the debate over my constituency, which is the position of the royal colleges. The Royal College of Paediatrics and Child Health and the Royal College of Physicians will often go so far as to specify an ideal set of requirements from the medical point of view. I am sure if one were to ask about children's accident and emergency, the Royal College of Paediatrics and Child Health would say that it would sooner have a system where every accident and emergency facility had 24-hour paediatric consultants on site, rather than on call.

Those are all ideal standards and they are subject to an important clause—all things being equal. Things are rarely equal and guidance is rarely absolute. The point to be borne in mind is that the royal colleges are not representative of medical concern in total, but they do have an eye on issues that the public do not have in their frame, such as medical litigation and the regulation of their profession. Although they are important bodies to consult, they are not necessarily disinterested and they are not always comfortable with every forward change. I do not want to lapse into any unfortunate talk about producer interest, which my hon. Friend the Member for Oxford, West and Abingdon (Dr. Harris) and I agree is a completely improper way to discuss public services. The ball falls in the Government's court when striking a balance, and not in the court of the medical authorities.

I applaud the Government's increase in the number of trained paediatric staff and paediatric nurses, their encouragement of flexibility with regard to nurse practitioners, their encouragement of enhanced status for accident and emergency staff, and their preaching of the doctrine of clinical networks. They can have that for free—it is a wholly good move in the right direction. If we are to get the balance of accident and emergency right, all views, including those of the public, must be weighed seriously in the balance. Doctor does know best when it comes to ailments, but the best doctors—I hope that this applies to the Minister—are the best listeners.

Several hon. Members

rose—

Mr. Peter Atkinson (in the Chair)

Order. Front Benchers' contributions start at half-past 10, and three hon. Members wish to speak before that. With a simple mathematical division, that means about 10 minutes each.

9.57 am
Mr. Colin Pickthall (West Lancashire)

I will try very hard to keep to that. I want to use the case that was raised by the hon. Member for Southport (Dr. Pugh) to illustrate the problems of running smaller hospitals and of reconfiguring, or rationalising—whatever the appropriate euphemism is for what goes on. I thank the hon. Gentleman for opening the debate and for the rational and sensible way in which he has presented his case.

The hon. Gentleman and I share a hospital trust. The hospitals—they were formerly separate—are on two sites six miles apart, with one in Ormskirk in west Lancashire and one in Southport. The trust operates with two different strategic health authorities, two different primary care trusts and two different ambulance trusts, because its two halves are in Lancashire and Sefton. Putting west Lancashire and Southport together, we find that Ormskirk is around about the centre of that catchment area. Skelmersdale and Upholland are on the eastern edge of the area, next to Wigan. That is the most densely populated part of the whole area—about 50,000 people live there.

It is important for the Minister to bear in mind the fact that the main road, the A570, also links Skelmersdale to Southport, so anyone travelling from Skelmersdale to Southport for adult A and E must pass through the middle of Ormskirk, which is one of the worst traffic bottlenecks in the north-west. Debate about an Ormskirk bypass began in the 1930s, but it seems that we are still no closer to getting one.

The hon. Member for Southport and I inherited a long-standing problem that has created enormous public concern ever since the debate began about the amalgamation of the former Ormskirk, Formby and Southport hospitals. The debate began seriously in about 1993. I came into Parliament in 1992 and have spent part of my time during the whole of that period wrestling with the agonies of a hospital in difficulties. Public concern grew enormously at the time of the Shields review in 1998 and 1999, to which the hon. Gentleman referred.

For years, there were outraged discussions about hot and cold sites, and a tendency for the proponents of each site to attack those of the other one, which I am pleased that politicians tried to prevent most of the time, with some success. There were threats that patients would leak out of the district to other areas such as Liverpool or Greater Manchester if the amalgamation went ahead. In fact, many GPs in west Lancashire campaigned actively and said that they would send their patients not to the newly amalgamated hospital but eastwards to Greater Manchester.

After all that, Sir Robert Shields put together a report that was endorsed by the then Minister, my right hon. Friend the Member for Southampton, Itchen (Mr. Denham), and approved by the then Secretary of State, my right hon. Friend the Member for Darlington (Mr. Milburn). The report was endorsed—uneasily, perhaps—by the communities concerned and by their political representatives: the predecessor of the hon. Member for Southport, my hon. Friend the Member for Crosby (Mrs. Curtis-Thomas), local councils, community health councils and me. In outline, the compromise placed all children's services in a brand new centre in Ormskirk hospital.

Dr. Pugh

The hon. Gentleman mentioned the councils. I believe that the record shows that Sefton council opposed the changes—collectively, on a range of issues but, specifically, on transport links. It asked to meet the then Minister but was not granted an audience. Sefton council was opposed to the proposed changes at the time.

Mr. Pickthall

I am sure that that is true, and it is true also of West Lancashire district council, which did not want the changes and fought vigorously against them for a long period. However, the Shields report put together what seemed to most people a compromise that gave something to each side by not benefiting one site entirely at the expense of the other and by trying to work with the grain. However, I understand the hon. Gentleman's comments.

The compromise, which placed all children's services in a brand new building on the Ormskirk site, recognised that the vast majority of children in the overall area were in the traditional catchment area of Ormskirk hospital, particularly Skelmersdale. The services include children's A and E. On the other hand, adult acute services—surgery and, coming shortly, acute medicine and adult A and E—were to go to Southport. Despite all the flaws that the hon. Gentleman has analysed, we could, with difficulty, accept the compromise. I speak for West Lancashire.

There were other reconfigurations in the amalgamation, but the A and E, the children's services and the adult's services going to different sites were the main ones, and those that have caused all the dismay in my constituency as well as in the hon. Gentleman's, especially among people in Skelmersdale and Upholland, who have to travel through the middle of Ormskirk to get to the hospital in Southport, unless they take an enormously circuitous route.

Thanks to huge efforts by the national health service in the area and local politicians to explain reasons and problems, public understanding has been largely secured, if not public support. That was helped at my end—the Ormskirk end—by the primary care trust and the trust agreeing, originally at my suggestion, to build a minor injuries unit in Skelmersdale, where the main concerns were. As I understand it, a parallel minor injuries unit project is mooted for Southport, to meet at least some of the concerns expressed. That is only in the discussion stage, but in my view is a likelihood. The driving force behind all the change was the concern of the Department of Health and the royal colleges that each hospital was too small to guarantee a satisfactory or even safe service. As has been explained, that was compounded by problems with junior doctors' hours and the working time directive.

Shields's brief was to take all those problems into account. In all the public debate that ensued, the Lancashire ambulance trust—I cannot speak for the Mersey Regional ambulance trust because I do not know about that—was reassuring. It attended all the meetings and reiterated that it could manage the new situation. As I understand it, there have as yet been no problems getting people to and from Southport and Ormskirk. The situation now is that blue lamp and acute medicine services are, as we speak, being concentrated in Southport and maternity and paediatrics in Ormskirk, where they will shortly be housed in a brand new state-of-the-art building; it is not far from completion. That has cost many millions of pounds, for which I thank the Government, and I hope that the Minister will find time to visit it when it opens.

Recently, a group has arisen in Southport that has woken up to the fact that those changes, which have been staring us in the face for four years and with which the hon. Member for Southport, I and many others have been grappling, have taken place. So politically astute is that group that it wrote to me and to many others in Ormskirk asking us to support the removal of children's services from the hospital in Ormskirk, a very unlikely request.

I can say something that the hon. Gentleman perhaps cannot easily say. The removal of children's services from Ormskirk, to be placed in Southport, which the group proposes, is daft and will not happen. Part of the group—I believe that it has a provisional wing—opposes the proposal to put a Southport minor injuries unit in place. If ever there were a place that would suit such a unit, although I suggest this humbly because it is not my patch, a seaside resort with millions of visitors would seem to be it.

In my remaining two minutes, I shall raise a couple of general issues that arise from the problem.

Dr. Pugh

I would hate the hon. Gentleman to blight the thousands of people who have campaigned against some of the changes in Southport. I am a member of the group that has written to him, but I was unaware that the letter had been sent to him.

Mr. Pickthall

Indeed it was, some time ago. I was very interested by it. My constituency is undergoing a rationalisation of its hospitals. At the same time, it is undergoing a review of its schools to remove surplus places, which will result in the closure of several primary schools. It is hard to judge which of those arouses most concern and, I must say, most local hysteria—there is some of that. There is a tendency to extrapolate. It is well known in Ormskirk that the Government intend to turn Ormskirk hospital into a BUPA hospital and flog it off. It is wonderful where these ideas come from. It is important that all involved in the process speak rationally, and explain and listen carefully, without jumping on some of the local bandwagons.

Hospitals and emergency provisions are changing. Specialisms are becoming more special and vastly more expensive. Many expertises are in short supply. Some reconfiguration is inevitable, therefore, and must be managed with enormous care and some give and take. Areas such as mine, which is bordered on three sides by major metropolitan areas with huge hospitals, some of which are only 20 minutes away, cannot easily sustain small, local general hospitals. Compared with many areas in the country, journeys of six to 10 miles amount to virtually instant access. People think nothing of travelling six miles across London to a particular hospital. People in your constituency, Mr. Atkinson, may well think that a hospital six miles away is fairly convenient.

To secure a comprehensive and modern maternity, paediatrics and children's accident and emergency department such as the one being built in Ormskirk is substantial compensation for additional journey time. Paramedics in ambulances play a pivotal role. They make the crucial initial stabilisation and decisions about where to go for the best possible treatment. One ambulance officer told us in a public meeting that people in an ambulance are far better off being taken to the right place than being taken to the wrong place and having to be bounced off to somewhere else.

The development of telecommunication—in our case, there are already links with Alder Hey—and of NHS Direct provide new alternatives for children as well as adults, dealing with serious and light problems. The minor injuries units will offer further alternatives.

The matter is important and affects many other constituencies and areas in the country, but few have the complication of being in two different authorities for almost all purposes. It is a difficulty, but the compromise reached by Sir Robert Shields seemed the best that could be arrived at in community and social terms at that time.

10.12 am
Dr. Richard Taylor (Wyre Forest)

I congratulate the hon. Member for Southport (Dr. Pugh) on securing this crucial debate, which is near to my heart. I will relieve the Minister of any worries: I will not speak too much about local affairs—I will say just a little.

I absolutely agree that the ball is in the Government's court. Like the hon. Member for Southport, I welcome the Government's commitment to real consultation. That is expressed time and again in "Keeping the NHS Local". The establishment of overview and scrutiny committees and the reconfiguration panel are welcome. It is interesting that the first time that the reconfiguration panel was used, in Kent, it came down on the side of patients and citizens. The hon. Members involved must be awfully careful not to be seen to be defending their own patches, because that is exactly the sort of divide-and-rule technique that has been used in our part of the world.

Conventional consultation, as the Government have spotted, completely misses the point. There was a useful article in the Health Service Journal just last week referring to the current consultation on Barnet and Chase Farm hospitals. The hospitals are only five miles apart, yet the pressure has been taken out of the process by guarantees that both accident and emergency departments will remain. There is a crucial sentence in the article—at long last, somebody is realising that access means entirely different things to patients and to health service managers: To a manager, 'access' means waiting times, but to an elderly person without a car, it means bus and train services to the hospital. To the elderly, access is purely and simply about distance and time, and the ease of getting there.

It has been hinted that we are approaching a collision. We have the needs and desires of patients and citizens on one side, and the clinical professions saying what is safe and possible on the other—and the Government are right in the middle. The citizens' wish is to travel for elective surgery, for which they can plan; they do not mind going to the best place for the operation because they can plan for it. However, they want bread-and-butter emergency treatment to be available near to them.

I shall refer briefly to Kidderminster in order to demonstrate to the Minister something that I suspect he already knows—if one takes three virtually equal accident and emergency departments, each with between 43,000 and 45,000 patients per year, and shuts one, the other two will be overloaded. That is particularly so if the one that is shut is left with a minor injuries unit but without a doctor, because it will not be able to treat anyone who may need admission. It will lead to queues in A and E departments and to demoralised staff. That was clearly demonstrated by the ambulance service's mileage: one month before the hospital was downgraded, it was 8,000 miles, but 12 months later it was more than 24,000 miles—a step of three times. The medical assessment units put in to take the load off A and E departments do not altogether work if the remaining hospitals are stretched. Only this week—it is referred to in today's papers—local medical assessment units have had to close.

There is a big myth about telemedicine. If a patient who lives in the wilds of Manitoba cannot be moved, telemedicine can be set up to a major hospital, which can take a surgeon through an operation he has not done before. However, experience of telemedicine here is that the machinery is often down and that the people at the far end are often too busy to respond. In my constituency, telemedicine is used less and less.

Turning to the clinical profession, I agree with the hon. Member for Southport that, by and large, doctors like the slightly easier life of working in a big unit. However, although it is much easier to provide a safe service in such big units, there has to be some compromise. I believe that the Government are working hard on the problem. Indeed, I am sure that the Minister takes a copy of "Keeping the NHS Local" to bed every night, because it is so important. It shows that the Government are thinking really hard about the alternatives.

For instance, the European working time directive will make it difficult to maintain many A and E departments. The Government are trialling four solutions in different parts of the country, all of which will retain a certain amount of local emergency work. I am waiting to see the details of the local emergency centre planned for Canterbury and to discover exactly how effective that will be.

The European working time directive is a time bomb waiting to explode. I would like for a few moments to impress the extent of the problem upon hon. Members. Of hospitals that serve fewer than 150,000 people, several have A and E departments. They include those in Bassetlaw, Grantham, Banbury, Weston-super-Mare, Halton general hospital in Runcorn and, I am afraid to say, Mr. Atkinson, the hospital in Hexham. As for hospitals with fewer than 150 beds, according to my sources, 36 apparently have A and E departments, including the Montagu hospital in Yorkshire and hospitals in Llandudno, Bridlington, Newark, Clacton and Louth. I could continue. There is a threat not only to services at those hospitals, but to services at some large units that are close together, which face problems because of the European working time directive. Shrewsbury and Telford are close together, as the hon. Member for Shrewsbury and Atcham (Mr. Marsden) knows, and we have heard about Ormskirk and Southport, but Falkirk and Stirling, Wakefield and Pontefract, Cheltenham and Gloucester, and Watford and Hemel Hempstead are also threatened. There is a time bomb waiting to explode.

The Government's job is to provide what patients need and desire and to make it possible for clinical staff to deliver a safe service in those circumstances. Compromises are necessary, but local people need bread-and-butter, local emergency services.

10.20 am
Mr. Peter Luff (Mid-Worcestershire)

I congratulate the hon. Member for Southport (Dr. Pugh) on securing this debate and on his substantial contribution to it. I am grateful to the hon. Member for Wyre Forest (Dr. Taylor) whose comments enable me to curtail my comments because, inevitably, he and I have a similar perception of the issues he raised. I am sorry that he had to curtail his comments to enable me to speak, because his expertise provided a useful contribution. I echo what he said about consultation and keeping the NHS local.

We recently had an unsatisfactory consultation exercise in south Worcestershire, which led to the downgrading of the minor injuries unit at Evesham community hospital. Thanks to a corrected parliamentary answer, something I had not received before, I understand that that consultation was probably illegal, having been conducted during a local government election. I am grateful to the Department for correcting its earlier answer.

I want to make two basic points. Accident and emergency departments are often misused by us, the patients, and over-centralised, as the hon. Members for West Lancashire (Mr. Pickthall) and for Southport said, but they are often put under excess pressure for other reasons. I am making no criticism of local accident and emergency staff. My son was treated at the Worcestershire Royal hospital only a few months ago for a suspected broken back, and the quality of treatment he received was remarkable. That was a genuine emergency to which the hospital and the accident and emergency service responded magnificently. I am glad to say that he sustained only severe bruising, but he had to walk many hundreds of yards with a severely bruised back to the car park, because there is totally inadequate car parking provision at the hospital—but that is another matter.

I broke my finger some weeks ago when boarding a fishing vessel as part of the armed forces parliamentary scheme. On reflection, I should have gone to the accident and emergency department of Worcestershire Royal hospital, but I did not. The fracture set badly and I cannot get my wedding ring off, which I am sure my wife is pleased about. The psychology is interesting. I was not prepared to go and wait six or eight hours, which is common in accident and emergency departments for routine injuries such as a broken finger. I should have practised what I preach and gone to the minor injuries unit at Evesham community hospital, but I did not think to do so. I regret that mistake, because of the problem I now have with my finger—particularly as I am left-handed—which has lost some of its strength and, more significantly, because minor injuries units have a huge role to play is removing an unnecessary work load from accident and emergency departments.

The tragedy is that the minor injuries unit at Evesham community hospital, as a result of the botched consultation by the primary care trust, has been downgraded and has lost a staff member. That has serious consequences. The former matron wrote to the primary care trust to object to the proposal, but it has been implemented. The primary care trust argued that not enough people used it—I freely admit that it is not used enough—and that it could not justify two permanent members of staff. I suggest that the correct solution was to promote the unit more effectively to take pressure off the accident and emergency department at Worcestershire Royal hospital and probably even the Alexandra hospital at Redditch. However, that was not done and the unit was downgraded, which I fear is the first stage of its total abolition. Minor injuries units have a huge role to play in supporting accident and emergency departments. It is a tragedy that that is happening in Worcestershire, and I suspect that the pattern is being repeated elsewhere in the country.

The hon. Member for Wyre Forest also referred to medical assessment units and their important role. The unit at the Worcestershire Royal hospital is a great success and we all welcome it, but sadly it has closed twice during the summer—once in August and once on Monday this week. South Worcestershire primary care trust sent out a fax on Monday 8 September, which was sent to me by a local GP, stating that the hospital was requesting four hours of respite for their Medical Assessment Unit. It is respite care for the health service. The fax concluded: Patients requiring urgent medical attention should continue to be sent to the accident and emergency department where they will be tended to as normal. I have, of course, talked to local GPs, who say that their response was to send more people to the accident and emergency department. The problem was not solved; it was transferred. I do not know whether that has been repeated elsewhere in the country, but the pressures on the medical assessment unit are clearly unacceptable because it has had to close twice during the summer and early autumn, when there are no epidemics, emergencies or crashes on the motorway. There have been no systemic problems, but it has had to close down twice—once for two hours and once for four hours. What will be the impact on the accident and emergency department if we get a flu epidemic in a bad winter?

To his great credit, the former Secretary of State for Health acknowledged that the Worcestershire health economy lacks capacity—a point made by the hon. Member for Wyre Forest. Problems are inevitably created when an accident and emergency department is closed. The capacity problem is made worse by Government targets, which distort local decision making. For example, we would not have downgraded the minor injuries unit at Evesham; we would have upgraded it and promoted it better. However, the primary care trust must meet specific targets laid down by the Government, so it had no choice—I feel sorry for it.

It is a question not only of Government policy and capacity but of ensuring that the accident and emergency departments are used properly. Many of our constituents are confused by titles such as minor injuries unit, accident and emergency and casualty—a word that they still know very well. What are those titles all about? We must work towards a better definition of the use of accident and emergency departments.

When I made a similar speech commenting on the lack of capacity in the local health economy, the hon. Member for Worcester (Mr. Foster) said that it was outrageous, because I would deter parents from taking children with temperatures to their local accident and emergency department. I replied that children with temperatures should not be taken first to accident and emergency. Yes, they might have meningitis, of which their temperature might be a worrying symptom, but they should start elsewhere in the system.

Parents should probably start with their pharmacist—a much under-used resource. Pharmacists could take pressure off accident and emergency departments. They should talk to their GP. They should talk to NHS Direct, which the hon. Member for West Lancashire referred to. I have my reservations about that organisation, but it is there. It would be better to discuss the case of a child with a temperature over the phone rather than rushing to an accident and emergency department, which denies other people with more threatening conditions access to treatment. GPs have out-of-hours centres, which are better places than accident and emergency to take that kind of ailment. There are also minor injuries units and medical assessment units.

Accident and emergency departments are often confronted with problems that are not medical. Such problems are the concern of the local education authority, the social services department or even the police. We must educate people to use accident and emergency departments better.

We are suffering in our county from a genuine double whammy. There is a systemic problem of people misunderstanding how to access the health service appropriately, which clogs up accident and emergency departments in Redditch and Worcester. Worryingly, ambulances have been queueing outside our accident and emergency department, where six to eight-hour waits are not infrequent. The fine staff in the health service generally, and certainly in our county, deserve better from both the Government and patients.

Worcestershire Acute Hospitals NHS trust has a fine new chief executive, who has a strong team of clinicians beneath him—some might say above him. Both the state and the citizen have a role to play in ensuring that all accident and emergency departments are used properly and serve the people effectively, and that is certainly the case in our county. I hope that the Minister will find ways to address the serious capacity problem in our county. As we approach the winter, I am fearful of what I will see in our local accident and emergency departments.

10.29 am
Dr. Evan Harris (Oxford, West and Abingdon)

I thank my hon. Friend the Member for Southport (Dr. Pugh) for allowing us an opportunity to debate accident and emergency provision. I applaud the expert way in which he has led the campaign locally, and the rational and effective way in which he has put his case today. He raised some serious questions for the Minister to answer, not least about the logic of the proposed arrangements. Since it was a Minister who altered the Shields report, the Government must take responsibility under current arrangements for the decisions that have been made, and be accountable for those decisions to local people and to the numbers of visitors to A and E departments in tourist destinations such as Southport.

We had a helpful contribution along the same lines from the hon. Member for West Lancashire (Mr, Pickthall), and a characteristic contribution, in its expertise and research, from the hon. Member for Wyre Forest (Dr. Taylor), who drew attention to the implications of some matters that I shall turn to later, including the working time directive. The hon. Member for Mid-Worcestershire (Mr. Luff) made some important points about the appropriate use of A and E services, which I shall also touch on.

The Government have raised expectations of having accessible A and E departments. They have focused on A and E services under the term "modernisation", which is sometimes a euphemism for interference, although not always. They have also raised expectations by calling a document "Keeping the NHS Local". Many hon. Members have already referred to the sentiments expressed in that reconfiguration document. It leads people to believe that they will be able to access their NHS locally, without some of the problems that we have heard reported in this debate. Again, it will be up to Ministers to defend the standard of service about which they seek to raise expectations when they title documents in such a way. The Government have an alternative: they could call a document "Look, we have a problem here", with regard to the number of doctors per head of population, the European working time directive and the pressure from the Royal Colleges, rightly or wrongly, over critical mass and training. However, they have chosen to stick with the language, "Keeping the NHS Local", and they will need to defend that.

The biggest threat to patient care and to the lives of patients in emergency situations is not the particular configuration of A and E departments, although that is postulated as a factor, but the capacity of our hospitals and, for the sickest patients, the continuing shortage, relative to need, of intensive treatment unit beds. When we heard of the tragic case of the child being ferried around in an ambulance between various hospitals in the north of England a few years ago, the key point was the shortage of ITU beds, not the configuration of A and E departments. Far too much can be made of whether there is adequate back-up of consultant staffing. For the sickest patients, we need to ensure that we have adequate numbers of ITU beds and adequate escorted transfer arrangements.

My hon. Friend the Member for Southport quite rightly said that there were general issues to consider. Those include the impact of the European working time directive and the need to ensure adequate training for junior doctors in all hospitals, not just smaller units. Sometimes their training is worse in larger units because they are there simply for service purposes. Another issue is the changing gender ratios in the medical profession, which will mean that, overall, doctors who have been considered full-time will be spending some time working less than full-time. There are questions over whether there could be too much status attached to working in large units and not enough research opportunities in partnership for those in smaller units.

I shall spend most of my time today questioning the Government on their approach on targets. The Minister will have heard before my concerns, which I have been raising for six years now, over the way in which they have imposed targets on the health service that work against the best interests of patients and of the service. It would appear that only when the targets are going in the right direction is it in the interests of Ministers.

The Government have imposed targets on A and E departments. The 12-hour maximum wait, which is curiously defined as being on a trolley, and the four-hour target for processing people through the department both use the wrong measures. Even if those measures are not applied as brutally as the Government suggest, with their, "You are a failing hospital; you are a failing manager; you are failing your staff if you do not meet those targets", there is no doubt that they are applied and measured wrongly. That concentration has damaged patient care and distorted clinical priorities. The 12-hour target is not a target from presentation at A and E to finding a bed but between a decision to admit and being denoted to be in a bed; and a decision to admit can be taken many hours after patients arrive at the department, even if they obviously require admission.

When is a bed a bed? That depends on whether the target is about to be breached. The morphological changes that one sees at the 11-hour stage is either the stuff of science fiction or the manipulation of the measures in such a way as to make them practically worthless. The Government declared in advance that they were going to measure the performance of A and E departments during the last week of March, and they gave hospitals ample time to clear the decks so that they could be seen to be meeting the targets.

I raised the matter with the previous Minister, now a Constitutional Affairs Minister, the hon. Member for Tottenham (Mr. Lammy). I asked him at oral questions on 3 June 2003 whether he was embarrassed about the number of trusts that were forced to meet the target. At columns 2 and 3, I quoted a BMA survey showing that a majority of respondents in A and E departments felt that the measures taken had distorted clinical priorities … and many said that waiting times for patients with the most serious conditions had increased. I pointed out that the survey also showed that patients were being rushed through A & E, inappropriately admitted, or transferred to the wrong department.

Believe it or not, the Minister's response was that the BMA had surveyed only 30 per cent. of its members. In fact, the survey was of 30 per cent. of A and E departments. For the first time in polling history, it seems that sampling 30 per cent. of a large and appropriate population is not felt to be satisfactory. That will be news for the Labour party's polling operation, which probably manages to poll about 0.003 per cent. of the population before saying, "This is what people want." It is astonishing that the Minister should say that the wrong 30 per cent. had been sampled and that everything was hunky-dory for the other 70 per cent.

Next we see the operation of spin, because the Government recognise that the targets are now associated with negative publicity. What did the Minister say? He said that it is not a target but a "milestone". The target has been rebadged as a milestone. I think that hospital staff see it more as a millstone, as it shows that the Government's policy of being "tough on trolleys, tough on the causes of trolleys" is detrimental to the work of accident and emergency departments.

There is now increasing evidence—it was mentioned in the newspapers only this week—that some patients need to stay in A and E, in a lit area with expert staff and resuscitation facilities, while they are being stabilised, especially if they are unconscious. I put it to the Minister that they are not going to protest about the relative discomfort of being in A and E, but instead we see the dangerous practice of transferring critically ill patients to beds on side wards in the ophthalmology department instead of being allowed to be stabilised by A and E departments. That makes A and E departments more like processing units than a speciality of medicine. No wonder morale is so poor.

Certain cases really need to be dealt with in A and E departments, such as people who have overdosed on alcohol and who need to sleep it off in A and E so that any underlying illness or condition can be assessed. If they are put on the wards, not only will they disturb other patients, as can be imagined, but they will not receive the neurological observation that they need. The Government need to drop this whole target culture, and in particular the targets that they have imposed on A and E departments.

There has also been talk of A and E units being run as private ventures. I do not think that the Government can be held responsible for what entrepreneurs do, but it is wrong to assume that they will not create problems for the NHS. They will cherry-pick patients who are not so sick that they require ambulances and will take staff from the NHS—and they will take a higher proportion of staff than they will take patients.

Mr. Paul Marsden (Shrewsbury and Atcham)

I am all in favour of diversity in health care provision. However, the NHS should be free at the point of delivery. Does my hon. Friend agree that there is a danger that patients could be turned away from private A and E clinics or forced to pay money that they cannot afford for services to which they should have a right?

Dr. Harris

Private A and E departments will find it difficult, because although they are offering a £29 initial service, the price will rise steeply if other investigations are required. I do not know what they will do with people whom they find to be ill but who cannot afford or do not wish to pay the additional amount; they will have a difficult job.

The European working time directive creates huge pressures on the Government, and they need to be clear about how they will tackle the problem. They have said that they will not seek an extension, but they have to recognise that there are implications for either the viability of departments or the quality of care delivered in those departments. It could pose a big threat to local services, and we want to hear answers from the Minister.

10.40 am
Chris Grayling (Epsom and Ewell)

Given the problems that we have heard about, it is ironic that we are having this debate at a time when record amounts of money are going into the NHS. One is forced to ask what is going on and why.

I congratulate the hon. Member for Southport (Dr. Pugh) on having secured the debate, which provided an opportunity to raise important local and national issues with the Minister. There have been two themes. The first was local hospitals, smaller units and the future of the A and E departments in such units. We heard about a number of constituency issues, and I crave the indulgence of the Chamber in putting some of my own to the Minister. They illustrate problems that affect many Members of Parliament, and reflect the unease within communities about the future of the health services on which they have depended for many years.

The second theme, highlighted by the hon. Member for Oxford, West and Abingdon (Dr. Harris), was the way in which staff in our A and E departments are let down by the Government's determined target, or milestone, culture. In accident and emergency departments, we see the NHS at its best, saving people who are seriously ill and putting them back on the road to recovery. Those are the first steps towards turning round situations that may be critical. The staff in A and E departments are fine professionals and do not deserve to have their work distorted, as is happening now, by a Government obsessed with numbers.

Nowhere is that obsession more evident than in A and E. In the past 12 months, the four-hour target has been at the heart of the target culture in the NHS. That is not wrong as an aspiration. None of us wants to see patients waiting for a long time in A and E departments. However, in conversation with health care professionals, we Members of Parliament hear how the target is distorting clinical decisions. A few weeks ago, I spoke to a consultant in a diabetic clinic, who holds an out-patient clinic every week. Sometimes, seriously ill patients need to be admitted quickly to hospital, but it is necessary to phone the A and E department first to ensure that nobody has been waiting for close to the four-hour limit, as they must take priority. That has nothing to do with health or with urgency of care needs. The need is to meet the target.

This time last year, we experienced the absurd situation of ambulances queuing outside A and E departments so that the four-hour wait figures for those departments were not damaged. The departments accepted patients only when they were ready to do so, and people had to wait outside in ambulances until they were taken in. That was ludicrous. Then, as the hon. Member for Oxford, West and Abingdon pointed out, there was the absurdity of the last week in March. With one week to meet the target, not surprisingly, hospitals threw in the kitchen sink in order to keep their stars and their reputations. Those that did not, suffered. I think of the example of a hospital on the south coast that lost star ratings because it behaved properly and followed conventional norms, and did not try to distort what it was doing that week.

In the words of the president of the British Association for Accident and Emergency Medicine, There is a feeling of panic out there at the moment. All sorts of quick-term fixes are being tried. Money appears to be no object, with staff being recruited and paid whatever necessary for the measuring period. That is nowhere near a proper and appropriate way to run a health service. Unsurprisingly, most hospitals met, or were close to meeting, the target. The figures however, were highly dubious. There is plenty of anecdotal evidence to suggest that figures have sunk back to previous levels.

I was fascinated by the figures given to me by the strategic health authority in my area, which showed that throughout most of the first part of this year, the average achievement throughout its hospitals was that some 80 per cent. of people attending A and E got away in under four hours. In week 13, however, the figure went up to 88.4 per cent. We know that it has come down again since then.

The British Medical Association and the medical profession have been outraged by this absurd and disgraceful situation, which Ministers defend in the House of Commons. I do not blame the Minister, who is new to the job of Minister and was not in position when that was happening at the start of March, but I say, as did the hon. Member for Oxford, West and Abingdon, that it must not be allowed to happen again.

The BMA's response to the 30 per cent. of its members who took part in the survey is clear cut. An A and E consultant said: I am appalled to see how A&E departments have been forced into taking extraordinary measures for a week-long period just to meet political targets. It is completely immoral of the Government to claim that it is raising the standard of performance in the NHS when this is how they measure it. It is quite wrong for patients' expectations to be raised in this way. He went on to say that the Government's obsession with waiting times is nothing more than bean-counting. That culture must change. Will Ministers undertake to change the obsession with targets? Can we release our professionals from the burden that they must carry? Let us allow them to take clinical decisions in their own hospitals without having to worry about whether they are meeting the numbers target for that month.

The second and equally important issue, which the debate has already touched on, relates to the European working time directive, its potential impact on smaller hospitals and the changes taking place in them. The hon. Member for Wyre Forest (Dr. Taylor) was right to highlight the time bomb, as he called it, represented by the working time directive. There are smaller accident and emergency units throughout the country. We heard from two Members from Worcestershire and two Members from west Lancashire whose constituencies have accident and emergency units that face reconfiguration or closure because of the working time directive. It is costing hospitals millions. They need to employ doctors that the market cannot provide.

I was grateful, in an ironic way, to the chief executive of my local NHS trust, Epsom and St. Helier, who is about to leave his post. In what I can only describe as a stunningly ill-judged decision, he made a public statement, on behalf of the clinical service partnership representing all the local NHS bodies, that he aims to reconfigure services in my area. He chose to issue the statement without telling anyone, and attacked everyone who is challenging the plans. That was very foolish, and it will cause significant problems for the process after he has gone. He did, however, let the cat out of the bag, for which I am grateful, because the process is being advertised as an enhancement to local services.

The chief executive's statement is headed, "Don't be bullied into second best!" The revealing element, however, is the fourth paragraph, which states: As the Working Time Directive comes into force there will not be enough doctors to go round. In future, we will require eight to ten doctors to cover the same shifts where we currently have four or five. So it makes sense not to spread them too thinly by duplicating some services unnecessarily.

That means that throughout the country, including west Lancashire and Worcestershire, as we heard from the hon. Member for Wyre Forest and my hon. Friend the Member for Mid-Worcestershire (Mr. Luff), and in Epsom and Ewell and Hertfordshire, where great debates are taking place, smaller hospitals will lose their accident and emergency departments, either full-time or part-time. I say to my constituents that it is likely that in the next few months Epsom hospital will lose its 24-hour cover for proper surgery and accident and emergency, as a consequence of the changes that the directive will bring about.

The directive is costing the NHS millions of pounds. The medical profession describes it as a disaster. It is reported that even the Prime Minister thinks that it is one of the worst pieces of legislation to come from Brussels, yet the Government appear to be doing nothing to stop it. If, in the next few months, the Government cannot find a way to mitigate the directive's impact on the NHS, the consequences for local A and E departments, as well as other services, will be disastrous.

10.50 am
The Parliamentary Under-Secretary of State for Health (Dr. Stephen Ladyman)

I, too, congratulate the hon. Member for Southport (Dr. Pugh) on obtaining the debate, which will, I know, be of great interest to his constituents. It is also of great interest to me. I declare a small interest: I am one of the products of the Ormskirk hospital maternity unit. Whatever other criticisms the hon. Gentleman may level at that institution, it produces damn good sturdy stock.

I shall, if hon. Members do not mind, deal largely with the specific issues that the hon. Gentleman raised about Southport A and E. It is fair to use the limited time that I have to do that. If I have time afterwards, I shall deal with the more general issues, which there will, I do not doubt, be other opportunities to debate.

The reality of modern medicine—the way in which we must meet its demands—will increasingly mean that we have to consider the reconfiguration of hospitals. That will be a continuing process, not something that we do once, after which everything will be right. We shall have to find the best ways we can of carrying out consultation and making decisions on the basis of that consultation, covering all the aspects of the matter that have been raised, such as clinical safety and locality, to meet the demand for a high-quality clinical service.

We heard in the debate, particularly from the hon. Member for Southport and my hon. Friend the Member for West Lancashire (Mr. Pickthall), the range of opinions that are encountered. My hon. Friend showed us a picture of how a community engaged over a considerable period in consultation, led by an expert report by Professor Shields, and clawed towards a compromise solution with which, perhaps, many people were not 100 per cent. satisfied, but which met the need for a safe, high-quality service; met, broadly, the local community's needs; and answered many of the concerns of the different people in the community. Reaching such a compromise is an incredibly difficult process, and I congratulate my hon. Friend and those who, when the compromise was reached, were prepared to say, "Well, maybe it isn't exactly what I would have come up with, but it is a compromise. It meets all the demands and has come about as a result of a lot of local discussion and consultation."

On the other hand, the constituents of the hon. Member for Southport obviously feel very upset about part of what has been decided, and are not able to accept that final position. However, sooner or later, the Government and the local health authority must say, "This is what we are going to do. We shall try to make it work." We have reached that stage in Southport and Ormskirk, and we believe that the solution meets the demands of the local population.

I have always said in debates in this Chamber and in the House that I am accessible; I hope that I am a listening Minister. I make the hon. Member for Southport the one promise that he asked me to make—to ensure that everything that he and my hon. Friend spoke about will be reviewed. We shall take a fresh look at the matter, and make sure that the local health trust does too, in the light of his comments. We shall proceed from there. However, I cannot promise that, having listened to him today, I shall unwind all the decisions and take a completely different, fresh view.

The hon. Member for Wyre Forest (Dr. Taylor) touched on some of the difficulties that we must consider in making decisions. They include locality, clinical safety, the working time directive and the need to maintain high standards of training, which we are told can really be offered only in large centres. He said that someone has to find a compromise, and he is right, and we must set our priorities on the basis of clinical safety.

I offer this suggestion to Private Eye, which runs a cartoon called, "Sights you seldom see". When someone appears on television to say that service in the local A and E department has failed their relative, one will never see an Opposition MP leap up and say, "Yes, but that's all right. We had to make a compromise when we were reconfiguring the local hospitals, and we compromised clinical safety, but that's okay, we won't blame this Government for it." We must ensure that clinical safety is a clear priority in making decisions. Often, that will mean that smaller services have to move, and that will always be unpopular with local communities. That is a hard choice that we in government find ourselves having to make, whether we like it or not.

Having said that, I undertake to listen very carefully to all the concerns about the Southport situation and ensure that they are all thoroughly reviewed. I also highlight the fact that the reconfiguration is not taking place without resources, as my hon. Friend the Member for West Lancashire pointed out. It will include a major investment in the local hospitals and require the provision of state-of-the-art facilities that will raise the standards for all adults and children in the area. It will produce a sound, clinically safe and very high-quality service, to which people in both constituencies are entitled. If we can do that as well as meeting the points raised by the constituents of the hon. Member for Southport, we will. However, at this time, we have not found a solution that meets the needs of both parties and reaches the compromise that the hon. Member for Wyre Forest seeks.

Among the more general comments that have been made, the hon. Member for Mid-Worcestershire (Mr. Luff) raised an excellent and constructive point, with which I agree. We must find a way of helping people better to determine whether they should go to accident and emergency facilities, a minor injuries unit, a doctor's out-of-hours service, their own GP, NHS Direct, or, as the hon. Gentleman said, a pharmacy. People need to consider which of those perfectly valid options is appropriate at the time.

The hon. Gentleman is right: too many people turn up at A and E units when, clearly, their problem is not the sort of emergency that needs to be dealt with there. We must look for a way to guide people in the right direction. The Government are aware of and trying to deal with that.

The hon. Members for Oxford, West and Abingdon (Dr. Harris) and for Epsom and Ewell (Chris Grayling) mentioned targets. I shall spend just a few seconds talking about targets. What are they? They are a management tool by which we distil the wishes of the general population. We do not pluck targets out of the air and decide to impose them on the national health service. Instead, we ask ourselves what people want from our NHS. What direction do they want it to take? What important factors do they want addressed? Waiting times is an obvious one.

Dr. Harris

Have the general public been asked whether they want a maximum waiting time of four hours, even if it means that the health of more ill patients will be threatened by doctors pursuing the maximum waiting time for the most stable cases?

Dr. Ladyman

If the hon. Gentleman had waited for me to finish, I would have dealt with that point. The public tell us that they want to be seen quickly in accident and emergency departments. We find a management target that we can give to local trusts to encourage them to put sufficient resources into their accident and emergency departments to deliver on the wishes of the public. That is what the targets are for. There would be a world of difference, if the hon. Member for Oxford, West and Abingdon and I were to turn up tomorrow in an accident and emergency unit, and the doctor were to say to him, "You need to stay in this unit for longer than four hours—

Mr. Peter Atkinson (in the Chair)

Order. Time is up. We must move on to the next debate.

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