Emergency Care

Opposition Day — [1st Allotted Day] – in the House of Commons at 12:32 pm on 21st January 2009.

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Photo of Michael Martin Michael Martin Chair, Speaker's Committee on the Electoral Commission, Speaker of the House of Commons 12:32 pm, 21st January 2009

I inform the House that I have selected the amendment in the name of the Prime Minister.

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Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health 12:39 pm, 21st January 2009

I beg to move,

That this House
acknowledges the excellent reputation of emergency and urgent care services in the UK;
commends the expertise and dedication of NHS emergency and urgent care staff who work around the clock to provide a consistent and reliable service;
notes the strain placed on accident and emergency departments across the country from winter viruses, and commends NHS staff for their extra efforts to maintain services in the face of such pressures;
supports the improvement of acute hospital services and development of specialist centres where appropriate;
welcomes the recent report published by the College of Emergency Medicine, but notes with concern its conclusion that proposals for urgent care centres are clinically unproven and undermine the principle of patient choice;
regrets the lack of evidence to support models of service configuration which are centred on financial concerns and pressures arising from the European Working Time Directive;
deplores the Government's lack of urgency in addressing concerns raised over trauma care;
believes that the public should be given a more meaningful voice over the provision of local emergency services;
recognises the unique contribution made by community first responders;
recommends that the Government introduce a single number to access urgent and emergency care services;
and urges the Government to publish its delayed urgent care strategy, the consultation for which was published over two years ago.

In this, the first Opposition day debate of this Session, we have the opportunity to reiterate our support for the national health service, which is our No. 1 priority and that of the people of this country. Even in the midst of economic crisis, we must be aware of how vital it is that all of us can continue to call on the NHS when we need it, and to know that its staff will respond with the capacity required, as well as the commitment and compassion that they have always shown in treating us as patients when we go to hospital or otherwise access the NHS. That is never more necessary than when we need emergency care for ourselves or for our families. Over recent weeks, we have seen great pressures on the service, with cold weather; widespread infections; wards closed by norovirus; an influenza outbreak; staff, both as a result of that and for other reasons, falling sick; accident and emergency departments that have been stressed 24/7; and, consequentially, elective operations being cancelled.

Throughout all that, doctors, nurses and other NHS staff have coped and cared. I therefore want to start by thanking NHS staff, as many Members will have done personally in their constituencies. Right at the turn of the new year, I had an opportunity to visit Ipswich hospital and to speak directly to the staff working in the A and E department there, to thank them and to hear from them about all the pressures that I mentioned. To give the House an illustration of what this has meant for staff, I note that Sally Ferguson, who is chief nurse at Bradford Royal infirmary, said:

"Our staff have been working very hard, are working additional hours and we have delayed some non-urgent, planned operations. Our staff have shown incredible dedication and a massive thank-you must go to them."

We should not forget ambulance staff, for whom this has been an incredibly difficult time. Let me read this quote from Rob Ashford, who is chief operating officer at west midlands ambulance service:

"Many of our staff gave up their own time to work additional hours away from their families while others enjoyed themselves."

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Photo of Philip Davies Philip Davies Conservative, Shipley

I am grateful to my hon. Friend for thanking the staff at Bradford royal infirmary for their hard work. I can confirm that they work incredibly hard under difficult circumstances. Will he join me in thanking the staff at Airedale general hospital, which my constituents also use, because the staff there do an equally good job?

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Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

I am grateful to my hon. Friend and heartily endorse what he says.

Happily, it is agreed across this House that NHS staff working in emergency and urgent care services do a fabulous job. We depend on them, and over these recent weeks, in all parts of the country, they have not let us down; they have responded terrifically. That is appreciated by patients. A patient wrote to his local newspaper about staff at Leighton hospital just outside Crewe, saying:

"The doctors and nurses at the local A&E...all did everything they could to help me. Nothing at all was too much trouble for any of them. You are all a credit to yourselves and your professions."

Another patient, writing about Derbyshire Royal infirmary, said:

"The treatment and attention I received at the Derbyshire Royal Infirmary was nothing short of first class."

I could add more and more of just those kinds of commendations for NHS staff.

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Photo of Simon Burns Simon Burns Opposition Whip (Commons)

My hon. Friend rightly, like many hon. Members, praises, thanks and congratulates nursing staff and doctors in our hospitals and throughout the NHS. Does he agree that it is equally important to mention that the other unsung heroes of the NHS are the ancillary workers who provide the nuts and bolts of the operation of A and E departments and wards in our hospitals?

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Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

I am grateful to my hon. Friend. Staff at Broomfield hospital, which serves his constituency, will greatly appreciate his comments. I know from talking to staff across the NHS that we sometimes underestimate the contribution that is made by all its professions and ancillary staff. We simply cannot run hospitals without a wide range of staff being present in order to make it happen, particularly out of hours and at weekends. Services can slow down dramatically without ancillary services such as diagnostics, portering and cleaning, and pathology laboratories being available. They are critical to maintaining the level of service that we all hope to receive when we go into hospital.

Today, I want not only to express our thanks but to take the opportunity to make real our appreciation by understanding what the pressures experienced over recent weeks tell us about the capacity of the service, the impacts of Government policies and plans on emergency and urgent care services, and the need—which I express on behalf of NHS staff—for the implementation of long-overdue reforms to emergency care and its support structures.

Let me give the House an important example in relation to understanding the pressures. In London, primary care trusts have been commissioning services from hospitals based on the framework for action that was published by Lord Darzi in July 2007. It is interesting to make a comparison, in order to understand what is going on. I heard from an NHS trust in London that its accident and emergency attendances in the 11 weeks before Christmas were up 10 per cent. on the preceding 11 weeks, that the elective admissions to the hospital were 15 per cent. above the level predicted by the primary care trust, and that its A and E attendances, year on year, had gone up by nearly 10 per cent., even though the primary care trust had said that they would go down.

Lord Darzi's report said that, over the next 10 years, the number of attendances at A and E departments in London would go down by 60 per cent. He said that 10 per cent. of patients did not need to be seen at A and E, and that 50 per cent. would be seen in the Government's new polyclinics. Frankly, that is not happening. The number of attendances at A and E departments is going up.

Up and down the country, people in A and E departments have told me that, when it comes down to it—as it often did over Christmas and the new year—patients are not being treated in the community when they are seriously ill, or when they are just reasonably ill, if the services in the community are unable to function 24/7 to offer the necessary support. The emergency department is the provider of last resort. It cannot say no; it has to meet the demand that is placed on it.

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Photo of Angela Browning Angela Browning Conservative, Tiverton and Honiton

There seems to be an obvious correlation between the out-of-hours doctors service and people going to A and E when they could perhaps have been treated elsewhere. Also, I believe that NHS Direct is a very good scheme but, when I used it myself, I found there to be quite a time lag between making the initial call and a nurse ringing me back, followed by a doctor ringing me back and telling me to go to an A and E department. That covered a time span of five hours. If I had not had a little medical training, which gave me the confidence to know what the problem was, I might have become nervous and whipped my husband off to A and E a lot earlier. Does my hon. Friend think that there is a problem of people going off to A and E of their own accord as a result of that time lag?

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Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

I am grateful to my hon. Friend for making that important point. In this debate, we need to press the Government. She will note from our motion that we want the Government to introduce proposals for a new, single telephone number for NHS services. I agree that telephone access to the NHS is necessary, and that it is beneficial to patients, but we should not delude ourselves that it leads to a reduction in A and E attendances. There is no evidence that it does that, but it is an important additional means of access. However, having a single telephone number to provide direct access to ambulance services, out-of-hours services and telephone advice would mean that patients would not have to move from one service to another, resulting in long delays while their needs are interpreted in order to decide which service should respond. Such a single number is sorely lacking. Emergency calls should still go to 999, but it should be possible for a call to the single number to be upgraded to receive an emergency response if necessary.

We know that that is necessary, and I think that the Secretary of State would agree. We recommended it some time ago and it has been reflected in subsequent next stage reviews across the country. The Government just have to get on with it, but for some absurd reason, when they have already accepted part of our motion, they seem to have taken it out, suggesting that they are not going to do it. They should do it. The next stage review by Lord Darzi said that it would happen, but there has been no consultation by Ofcom on access to the new single number, which we need; I hope that it will be provided soon. At the same time, we need a document from the Government showing how that number can provide access not only to NHS Direct nationally, but to out-of-hours services, local services and ambulance services. If the Secretary of State wants to interrupt me now to tell me that the Government are going to make progress on a new national telephone number for accessing urgent care services, I would be happy to give way to him.

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Photo of David Evennett David Evennett Shadow Minister (Business, Innovation and Skills)

My hon. Friend is making a powerful case. I would like to commend the accident and emergency staff at Queen Mary's hospital in Sidcup, who did a tremendous job during the period that he highlighted. Is he aware that many residents in my borough, particularly the elderly, are very concerned about the future of those services because there is so much uncertainty?

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Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

My hon. Friend reminds me that I visited Queen Mary's in Sidcup in the autumn, when I had the opportunity to see the emergency services and maternity services proposals at work. Many people in south-east London will be concerned about emergency services because, leaving aside the geographical distribution of emergency services in the area and the question of access at normal times, they will worry about the capacity of those services to respond. That is part of the argument about A and E in London more generally. Many dramatic pressures and a lot of demand have been put on emergency services. The number of beds in hospitals in London has been cut and departments have been downgraded.

Joan Ryan will know that the Government are trying to downgrade the emergency services at Chase Farm hospital in her constituency to an urgent care centre. Just before Christmas, the College of Emergency Medicine published a document on the way forward for emergency medicine and it did not regard urgent care centres as clinically proven or consistent with the principle of patient choice. Emergency consultants in hospitals are criticising urgent care centres, so why are the Government persisting with them? I fear that we will see the same problem in Sidcup.

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Photo of Tony Baldry Tony Baldry Conservative, Banbury

It would be wrong to see the capacity challenges just as a winter issue. I have just done an analysis of capacity at the John Radcliffe hospital in Oxford, based on the advice that it gave to GPs on access from 1 July to 31 December last year. On average, patients in certain disciplines were being diverted away from the JR every other day because of lack of capacity. This is a year-round issue for certain disciplines, including A and E. Is not the nightmare that the full implementation of the European working time directive is coming towards us like a train down the track? It keeps people awake at night wondering how on earth our general hospitals, including hospitals as large as the JR, will manage when the directive is fully implemented.

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Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

My hon. Friend makes an important point, which also relates to emergency services in Banbury, even though he is talking about the John Radcliffe. I visited the emergency department at John Radcliffe about three years ago, and the quality of the redesign of emergency services and the service it provided struck me as remarkably good.

The issue of capacity is important. It is possible to have a magnificent system that works for normal levels of demand, but if there are abnormal levels of demand, we need to be able to respond to such surges. That is precisely the point made by the College of Emergency Medicine. It says that capacity in emergency departments is critical and that urgent care centres, walk-in centres, minor injury units and polyclinics may all have their place, but it would be foolish to think that they can substitute for emergency departments as the hub of the emergency care system. The resilience of the NHS to surges in demand such as the one that we have seen depends critically on emergency departments having the necessary resources—even more so if we were to encounter a pandemic. It is therefore vital that they are not downgraded or closed without regard to the implications or the evidence.

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Photo of Andrew Murrison Andrew Murrison Shadow Minister (Defence)

The high-tech end of medicine is extremely important, but would my hon. Friend agree that the wholesale closure of community hospitals has put considerable pressure on accident and emergency departments? In my area, for example, health care professionals are in no doubt that the closure of community hospitals has caused an increasing number of elderly and vulnerable people to end up in casualty departments, which is exactly where they should not be in the context of their long-term treatment.

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Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

My hon. Friend is very knowledgeable about these matters. I have discussed the issue with him and with the chairman of his primary care trust, who believes that community teams will be able to look after patients in the community and, as a consequence, avoid their admission to hospital. Let us look carefully at the experience of the past few weeks and find out whether it is possible to do that in practice. In reality, we have seen patients being admitted into hospitals all the same. I am sure that Ministers will know that many patients in hospitals have been transferred into escalation wards because of limited capacity; new capacity has to be created.

Quite often, community hospitals can provide a place to which patients can be transferred to relieve pressure on acute hospitals when demand is high, while at the same time they can provide a sort of step-up bed so that GPs can admit patients and observe them. That means community medical resources can be deployed through GPs to look after patients, instead of those patients having to be transferred to an acute hospital, which is the last place we would want many of them to be. Let us look at what is happening in Wiltshire, because a lot of beds have been lost in hospitals in my hon. Friend's constituency, and I wonder what the consequences of that loss have been.

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Photo of Joan Ryan Joan Ryan Labour, Enfield North

I am concerned about the selective and inaccurate way in which the hon. Gentleman is using the report to which his motion refers. I have read the report, not least because of the situation of my local hospital. He will know that the report does not help my argument, and I have my concerns about the Government's plans for Chase Farm hospital. I make my views about the matter clear to Ministers regularly. However, my point is that I am often struck by the difference between what he says in the Chamber and what his party did when in power. If it had not been for his party putting Chase Farm hospital under the threat of closure for many, many years, Chase Farm would not be in its current situation and—

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Photo of Michael Martin Michael Martin Chair, Speaker's Committee on the Electoral Commission, Speaker of the House of Commons

Order. This is an intervention, not a speech. The right hon. Lady might get an opportunity to make a speech.

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Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

Let us stay in this century shall we? The College of Emergency Medicine said in its report:

"We find the term 'Urgent Care Centre' misleading with no clear definition of the case mix, staffing or how they relate to the emergency departments. There is no evidence of the clinical or financial benefits of this model."

That is, however, precisely the model being pursued at Chase Farm. That model is being challenged locally by my colleagues and by the local authorities through judicial review, and it is incumbent on the Government, not least given the views presented by the College of Emergency Medicine, to call a halt. Given the pressures on London, they should reconsider whether Chase Farm should have a maintained emergency department, to meet demand.

As for what is being done by the strategic health authority in London, Ministers, in their amendment to our motion, do not seem to be responding to the pressures experienced by emergency departments in London by saying that they can help them. They are responding by calling them to a meeting, hitting them over the head and saying, "You must meet the four-hour target." There are some excellent hospitals in London that are doing their level best to respond, and doing all that they can to treat patients as quickly as they can. It is far from helpful for them to be threatened by the strategic health authority because they are at 97.1 per cent. rather than 98 per cent. The College of Emergency Medicine has argued for a long time that in practice, a 95 per cent. target for the four-hour waiting time in accident and emergency departments is financially and clinically logical.

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Photo of David Wright David Wright Labour, Telford

I understand the hon. Gentleman's point about surge capacity in urgent care, but may I return him to the wider point about primary care services? They are critical, because primary care services in the community diminish the number of people presenting at A and E. Does he support extended GP opening hours and programmes for polyclinics? I am just trying to clarify the situation. Does he support initiatives to provide GP-led health care services and expand them in areas whose GP services are under-resourced? I am not talking about urgent care centres; I am trying to define whether Conservative Front Benchers support programmes to increase GP and walk-in services in communities.

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Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

We are all very concerned to have better access to primary care. The Commonwealth Fund, which Ministers are keen on quoting, published a report last year stating that of the countries that they examined in the survey that Ministers rely on, access to primary care was worst in the United Kingdom. It stated, for example, that out-of-hours evening and weekend access to primary care was available to 60 per cent. of people in this country, compared with 93 per cent. in Germany. Those figures were self-reported, and there is a big gap between where we are and where we ought to be. A lot of things contribute to that gap, but the central part of it is out-of-hours services.

The Government focus on the idea that what really matters is GPs sitting in their surgeries dealing with routine appointments at half-past 7 on a Thursday evening, as if that were the answer. However, they have implemented an out-of-hours GP contract that has had the effect of substantially diminishing access to primary care in the evening, at night and at weekends. It is no surprise that although about 14 per cent. of A and E attendances generally occur on each day of the week, the figure is about 16 per cent. on a Monday. We can therefore see that there is a substantial Monday morning increment in the demand on A and E departments. All the reports that emergency departments make to us suggest that that is a consequence of the poor access to primary care over weekends, which the Government are doing nothing to solve.

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Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

I shall give way one more time and then I must make some progress, because I do not want to take up too much time.

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Photo of Alistair Burt Alistair Burt Opposition Whip (Commons), Deputy Chair, Conservative Party

I am grateful to my hon. Friend, who has been extremely generous in giving time to colleagues. Before he leaves the issue of time pressures in the health service, I can confirm, from visiting Bedford hospital over the Christmas period, the pressures caused by the implications of the working time directive. Does he share my bewilderment as to why Labour MEPs did not vote to continue Britain's opt-out from the working time directive, knowing the implications for the health service and the problems that it would cause?

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Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

My hon. Friend makes a vital point. It is astonishing that Labour MEPs would not adhere even to their own Government's policy. That came after the Government's presidency of the European Council, when they were unable to deliver the required changes to the directive. A compromise was agreed in the Council of Ministers, but the Government appear incapable of getting it through the European Parliament. It is outrageous that British MEPs should vote in a way that damages the prospects of delivering care in our NHS.

In the light of all the pressure on A and E departments, we have to ensure that they are not downgraded or closed unless what is done is evidence-based. I know that Ministers will say that because some patients need to be referred to specialist centres, such as those for major trauma, paediatric intensive care, severe head injuries, heart attacks and strokes, all patients with severe illnesses or injuries should therefore go to a regional specialist centre. The evidence does not support that. For example, the Sheffield study in the Journal of Emergency Medicine, published in 2007, concluded that increased journey distance to hospital appeared to be associated with an increased risk of mortality, the strongest association being for patients with respiratory emergencies. The study did not include cardiac arrests.

The argument is clear for an understanding that some patients will bypass their local emergency departments and go to a specialist centre, particularly those in blue-light ambulances. Let us contemplate major trauma. It is very important to have regional trauma centres, and we need the trauma network to be developed in that way. We saw in a report published in November 2007 that less than half the patients suffering major trauma received the best standard of care. That was according to the national confidential inquiry. The report called for regional planning for trauma networks, but what has been the Government's response so far? A Minister in the House of Lords said that they were considering appointing another tsar to take on the task. We are more than a year on, and the Darzi review provided plenty of opportunity for something serious to be done about the problem, and for regional work to make something happen—but that simply has not happened.

We have been fighting accident and emergency reconfigurations. I give credit to my colleagues, because in Surrey and Sussex, for example, they have seen off plans that would have substantially undermined local capacity to offer emergency services. They have been fighting such plans elsewhere, for example in Hertfordshire, but I am afraid that they do not seem to have won so far in places such as Hemel Hempstead and Welwyn. I promise my colleagues, the House and the public that we, when in a government, will focus on ensuring that capacity is in place for the emergency services, and on not making accident and emergency reconfigurations unless they are backed by the decisions of local commissioners, such as the GPs who look after patients, and by clinical evidence of need. We will operate on that basis, and where necessary we will put a stop to misguided reconfiguration proposals.

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Photo of Ann Cryer Ann Cryer Labour, Keighley

Philip Davies, who is my MP, spoke in glowing terms about Bradford royal infirmary and Airedale hospital. I have frequently been a patient at the BRI, and Airedale hospital is in my constituency. Mr. Lansley is talking about outrageous this and outrageous that, but he is not offering solutions for one of the most outrageous occurrences in accident and emergency departments: the treatment of doctors, nurses and ancillary workers by members of the public who go in for treatment under the influence of either drink or drugs. On some occasions such patients are quite violent, which is truly outrageous. Does the hon. Gentleman have some magic solution to that? I do not think that there is one.

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Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

I understand the hon. Lady's point, but I think that she does us a disservice. My hon. Friend Mike Penning, not least, has made clear our determination to pursue prosecutions. To my recollection, there are something like 55,000 assaults a year on NHS staff, less than one in 1,000 of which leads to a prosecution. What is the point of putting up notices across NHS buildings saying that there will be zero tolerance of assaults on NHS staff if people know that in practice, those who commit exactly that offence will not be prosecuted?

We make it clear in our motion that we want an urgent care strategy. The Government have promised that; they held a consultation in October 2006 and published the responses six months later. Two years on, they have not published a strategy. They said that the matter would be dealt with in the Darzi review, but the final Darzi report contains two references to urgent care, which are essentially nothing more than references to the single telephone number that I have already talked about. Where, then, is the urgent care strategy that is required? Everywhere I go across the country, people are looking for urgent care networks and for a better structure of urgent care that better knits together A and E, walk-in centres, out-of-hours services, ambulance services and NHS Direct, and presents seamless joined-up care for patients. It is vital that we achieve that.

I thank the Government because they have accepted the first part of our motion in their amendment, and I appreciate that. Indeed, they have expressed their recognition of the work of community first responders. In some parts of the country, such as Cheshire, that is not reflected in the behaviour of the ambulance service. Community first responders in rural areas make a vital contribution to response times, especially category B response times, but their achievement does not appear to be recognised. However, I appreciate the Government's approach to that.

Despite that approach, the Government have gone on to delete a great deal that is necessary in the motion and replace it with some deeply flawed text. They persist with the idea that improvements in primary care and access to GPs is a substitute for access to emergency departments and emergency care. That is not the point, as the College of Emergency Medicine makes clear. It stated:

"It is disingenuous to compare a 24/7 service that cares for the whole spectrum of ill and injured patients with the care of routine patients in a GP surgery."

"Disingenuous" is not a word that I would normally apply to the Secretary of State. The idea probably emanated from the Minister of State, Mr. Bradshaw.

I hope that we have shown that we appreciate NHS staff who work in emergency care. I think that we show that we appreciate them if we listen to them. They need a major trauma network, but the Government are letting action on the national confidential inquiry report drift. The urgent care strategy and the single number seems to have been delayed and delayed, and the Government's assumption that patients will not turn up at accident and emergency has been proved false and—worse—dangerous. With beds being cut and A and E departments downgraded, the capacity to deal with surges in demand is being undermined. The evidence from the College of Emergency Medicine about A and E reconfigurations, which was published in December, is being ignored and the Government persist with their plans for urgent care centres in place of emergency departments, although the case for that is clinically unproven.

Emergency departments are central to the emergency care system. Instead of ignoring the views of emergency consultants and pushing polyclinics as a panacea for all ills, the Government should give emergency care the support and the structure that it needs to meet the demands that it faces in future. We will listen, not lecture. We will work with the evidence, not ignore it. We will act where the Government have drifted. I commend the motion to the House.

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Photo of Alan Johnson Alan Johnson The Secretary of State for Health 1:12 pm, 21st January 2009

I beg to move an amendment, to leave out from "appropriate" to the end of the Question and add:

"acknowledges that health professionals provide excellent emergency care to 19 million patients a year in England;
recognises the unique contribution made by community first responders;
notes that the four hour target maximum wait in accident and emergency is hailed by many as one of the most significant steps forward in improving services for patients;
welcomes the fact that patients can also access services through NHS Direct and 90 NHS walk-in centres and will soon see the benefits of 113 new GP practices in underdoctored areas and at least one new GP-led health centre in each primary care trust open seven days a week from 8 am to 8 pm;
and further notes that the removal of target maximum waits for treatment will increase waiting times for patients."

I welcome Mr. Lansley back to his former position after the reshuffle. Indeed, I was thinking how much I would have missed him if he had gone. I genuinely believe that we can have a debate about the motion and the amendment, which would make a change, and consider some of the issues that hon. Gentleman raised. I say that because the past couple of days have put me in a jovial mood. Yesterday, in America, Obama was inaugurated and one of the priorities, which he must tackle quickly, is the terrible problems in the health service there. In America, 46 million people are uninsured and 25 million people are underinsured. Insurance premiums have increased by 90 per cent. since 2000, whereas wages have gone up by a quarter of that. Harvard university estimates that half the bankruptcies in America are caused by medical bills. Compared with that, the issues that we are discussing and the political differences between us pale into insignificance. Barack Obama and many American politicians would like to have this sort of debate rather than the central debate that they must hold quickly about how to have an American health service that fulfils the needs of its people.

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Photo of Simon Burns Simon Burns Opposition Whip (Commons)

Would not the Secretary of State be even happier if President Obama had adopted the more extensive health care provisions of Hillary Rodham Clinton?

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Photo of Alan Johnson Alan Johnson The Secretary of State for Health

Let us wait and see. The problem with the Clinton proposals—it is questionable whether they were Bill's or Hillary's—is that they did not emerge until the September after the January inauguration, which was probably too late because the 100 days had passed. Secondly, they sought to overhaul the whole health system, whereas Obama is trying to examine the issues that present problems rather than those that do not.

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Photo of Simon Burns Simon Burns Opposition Whip (Commons)

I am sorry to say that I think that the Secretary of State is a little confused. He refers to the original proposals in 1992-93, whereas I meant the proposals on which Hillary Rodham Clinton fought the primary elections in 2007-08.

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Photo of Alan Johnson Alan Johnson The Secretary of State for Health

Indeed, I was referring to the original proposals, which I thought were hers as well. Let us move on to British politics.

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Photo of Andrew Murrison Andrew Murrison Shadow Minister (Defence)

I am worried that the Secretary of State may be a little complacent. I do not think that President Obama will wish to emulate our outcomes for common causes of morbidity and mortality, especially stroke, which I hope the right hon. Gentleman will consider shortly. America—indeed, most of the western world—does considerably better than us on that.

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Photo of Alan Johnson Alan Johnson The Secretary of State for Health

I am afraid that the hon. Gentleman is wrong. America spends 16 per cent. of its wealth on the health service—[Hon. Members: "Outcomes."] It has the poorest outcomes in the world for many health matters.

The Conservative party has crossed the Rubicon and supports a taxpayer-funded national health service, free at the point of need. The predecessors of the hon. Member for South Cambridgeshire, in the shadow Cabinet and when the Conservatives were in power, would have had a range of hon. Members sitting behind them who might have paid lip service to that but who were carefully making plans to undermine it—whether through the patient's passport or all the other variations on that. I therefore welcome the hon. Member for South Cambridgeshire back. I am glad that he was not moved to make way for Mr. Clarke—although, if the right hon. and learned Gentleman had taken the post, the love-in with the BMA would have ended quickly, given his previous record.

The hon. Member for South Cambridgeshire recognised that we support six of the 11 points in the motion. The Opposition commend

"the excellent reputation of emergency and urgent care services in the UK", and rightly pay tribute to NHS staff, especially given the winter that we have had. I shall say more about that shortly. The motion also

"supports the improvement of acute services and development of specialist centres where appropriate".

That is rather confusing, because specialist centres, especially specialist A and E and the need to ensure 24/7 cover by the very best people, form part of the debate that has gone on in the health service and I think, from his comments and propositions, that the hon. Gentleman supports that. However, the important words are "where appropriate". Who decides whether the centres are appropriate? That is a major issue.

The motion includes three issues with which we disagree. First, it refers to the report from the College of Emergency Medicine, which is a new organisation, in its first year. We welcome its report and hope that it prospers, but we disagree with the suggestion that the clinical case for urgent care centres is unproven.

Secondly, the motion refers to the

"lack of evidence to support models which are centred on financial concerns and pressures arising from the European Working Time Directive".

Thirdly, it refers to a lack of urgency in addressing concerns about trauma care.

There are a couple of neutral issues. We believe that the public should be given a more meaningful voice about the provision of local emergency services. We may disagree about the way in which that is done, and we do not agree that there has been delay in the urgent care strategy. I can understand, given the report that was produced two years ago— [Interruption.] I will deal with that shortly.

We want to hold a genuine debate about the motion and the amendment. As I said, like all Labour Members, I wholeheartedly join the hon. Member for South Cambridgeshire in acknowledging the excellent reputation of emergency and urgent care services in this country, and the dedication and commitment of NHS staff to providing an outstanding service to patients 24 hours a day, 365 days a year. I hope that he will join me in acknowledging the support that the Government have given the NHS: massive investment, doubling the number of emergency consultants, an increase of 135 per cent. in funding for ambulance services, and greater numbers of people in training, all of which lead to better, faster treatment, with greater patient satisfaction.

I hope that Opposition Members also recognise the steps that we have taken to improve the pay and conditions of staff in our emergency services. The hon. Member for South Cambridgeshire has suggested a day of celebration of nursing in this country. Given the plans of the shadow Chancellor and the Leader of the Opposition, that day might merge with the day when everyone looks back on when they had defined benefit pension contributions, because, as I understand it, while applauding the work of the 1.3 million people in the NHS, Opposition Members are also keen to attack their pensions.

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Photo of Alan Johnson Alan Johnson The Secretary of State for Health

The hon. Gentleman says, "Nonsense!" [ Interruption. ] Opposition Members are saying, "No, no, no!" The words of the Leader of the Opposition were that the private sector is moving from defined benefit to defined contribution schemes and that that has to be what we do in the public sector.

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Photo of Alan Johnson Alan Johnson The Secretary of State for Health

Absolutely—I did not say that it was, but that is what the Leader of the Opposition was saying. [ Interruption. ] We will get to the bottom of this before the next general election. As well as improving pay— [ Interruption. ] While we are on this point, the Leader of the Opposition has said quite clearly that there needs to be a move to defined contribution pension schemes. The hon. Gentleman can now intervene on me to say that a future Conservative Government will in no way interfere with the pension arrangements of NHS staff. I will take that intervention from him or any member of his Front-Bench team.

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Photo of Alan Johnson Alan Johnson The Secretary of State for Health

Ah! Well, that is very interesting.

As well as improving pay for staff on the lowest pay grades, "Agenda for Change", which was introduced in October 2004, has significantly improved the pay and conditions for ambulance staff in particular. They are no longer expected to work nights, weekends and public holidays for the same rates of pay as normal hours. Their pay has increased, as has the training and the professional development that they receive.

The hon. Member for South Cambridgeshire is right to say that winter pressures place additional strain on urgent and emergency care. As hon. Members will know, last month was the coldest December for 30 years. Increases in accidents, flu cases and other health problems associated with cold weather put the NHS under great pressure. In some hospitals that I visited, it was miraculous that the staff were keeping the service going at such high level of quality. At one hospital that I visited in Yorkshire, the amount of ice on the roads meant that it had to treat 200 fractures over four days. However, better planning, more staff and improved organisation have given the NHS the capacity to cope with such pressure without a return to the dreadful scenes of the early 1990s, when many A and E departments had to close because they could not cope with patient demand.

I agree that we should support further improvements of acute hospitals and develop more specialist centres. I would also like to point out that the abolition of long waits and greater investment in specialist centres for conditions such as stroke over the past 12 years has radically transformed patient care in our hospitals. I, too, welcome the report by the College of Emergency Medicine, but I take issue with the claim that the vital reconfigurations of urgent and emergency care services are motivated by financial constraints or that they are clinically unproven. Every reconfiguration of urgent and emergency care is clinically reviewed by the national clinical director for urgent and emergency care and his team. All decisions are taken on the basis that they will improve patient safety and improve the quality of care and that they balance these concerns against improving patient access.

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Photo of Paul Truswell Paul Truswell Labour, Pudsey

A few moments ago my right hon. Friend mentioned stroke, which Dr. Murrison raised earlier. Will he describe in a little more detail what the Government intend to do to raise professional and public awareness of stroke symptoms, improve access to scanning, ensure that acute stroke units are brought up to the standard of the best and look into the development of hyper-acute stroke units?

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Photo of Alan Johnson Alan Johnson The Secretary of State for Health

I recently had occasion to visit the health service in my hon. Friend's constituency. Stroke care is crucial. The stroke strategy that was adopted in December 2007, with the involvement of all the charities and experts, is being taken forward. The fast test, for a quick assessment of whether someone is suffering from a stroke, is now widely spread, in all GP surgeries. However, we are talking about a continuing programme, and my hon. Friend is right to raise the importance of stroke care in the NHS.

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Photo of Andrew Murrison Andrew Murrison Shadow Minister (Defence)

Does the Secretary of State agree that although stroke has emerged from the shadows as a true emergency because of the advent of imaging and thrombolysis, the United Kingdom has some of the worst outcomes in the western world? Will he also comment on the Stroke Association's assertion that

"access to acute emergency stroke services throughout the UK is...in need of urgent improvement"?

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Photo of Alan Johnson Alan Johnson The Secretary of State for Health

We all accepted when we came into power in 1997 that the three major killers—cancer, heart disease and stroke—needed to be tackled. They could not all be tackled at the same time and with the same intensity. However, it is fair to say that although we saw early improvements in cardiovascular disease and cancer in particular, stroke care came a little later. The hon. Gentleman is right to say that. I do not know when the Stroke Association said the words that he quoted, but it has worked closely with us to improve services. Neither we nor the Stroke Association believe that we have a perfect stroke care service. However, in relation to the very issues that we are discussing today, we do believe that as specialist centres are introduced more widely and as we put in more resources and implement the stroke strategy, outcomes will improve accordingly.

I was talking about how we deal with reconfigurations and what the Conservative motion says about the importance of concentrating services where appropriate. As part of his review last year, albeit that it was separated from the final publication by a couple of months, my noble Friend Lord Darzi set out clearly the rules that will govern the changes. I would be very surprised if there were any differences, given the importance that we all attach to moving with the times and implementing more specialist care. Lord Darzi said that change must

"always be to the benefit of patients," and that it must always be "clinically driven". Change must not come from a Richmond House edict, but must always be

"locally-led... Meeting the challenge of being a universal service," and recognising that

"Different places have different...needs".

Change must always involve patients, the public and local staff. If proposals are adopted and change is to occur, the local population has to see the benefits in place first, before the changes occur. That means some quite expensive but very necessary double running to ensure that things work. That seems to be the perfect model in a world where no one is suggesting—I presume that that includes those on the Opposition Front Bench—that there must be no change and no so-called reconfigurations whatever.

Professionals estimate that between 50 and 70 per cent. of people who turn up at A and E would be better treated elsewhere. The majority would be better treated in primary care—that is why primary capacity is so important, as my hon. Friends have rightly pointed out—or in minor injuries units or urgent care centres. Our urgent and emergency care services see patients with a huge range of conditions, from a major trauma to a broken finger. It is nonsense to suggest that a patient who has twisted an ankle is always best accommodated alongside a patient who has had a heart attack or been seriously injured in a road accident. To deal with major trauma or severe injury successfully, A and E departments need the right concentration of expert staff to assess critically ill patients quickly. In many areas, there will be two A and E departments in relatively close proximity to each other, trying to do that as well as deal with many less serious complaints. That is why many SHAs are taking decisions to concentrate expert A and E staff in one hospital and equip the other to deal with more minor complaints. That is what has happened successfully in areas right across the country. The suggestion that these decisions are being taken because of the European working time directive is, frankly, laughable.

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Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

Does the Secretary of State agree or disagree with the College of Emergency Medicine when it argues that, for a proportion of patients, distance to an emergency department is a significant risk factor in overall outcomes? Its document published just a month ago says:

"Where the next nearest Emergency Department is more than 20 kilometres away, there is a strong argument for retaining an emergency service."

Does the Secretary of State agree or disagree with that principle?

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Photo of Alan Johnson Alan Johnson The Secretary of State for Health

I would broadly agree with it; there is a strong argument for that, but it has to be decided locally. That college does not say that a hard and fast rule should be set in all circumstances. The major thrust of the report, representing as it does A and E consultants, is that we should double the number of such consultants—having doubled them already! When I was leader of the Communication Workers Union, not a single report it issued failed to suggest that more of my members were needed somewhere in British Telecom or the Post Office, so I am not surprised by that report. It also says, however, that there is no single solution to the reorganisation of emergency care. It makes the point that in urban areas where emergency departments are close together—the very point I just made—there may be advantages to amalgamating some services. On the whole, it is a bit sceptical and it makes the point about long distances, but I do not think there is anything between us if we are guided by the five principles set out by my noble Friend Lord Darzi, who knows more about the health service than all of us put together—more even than the hon. Member for South Cambridgeshire. Let us say rather that he has forgotten more than we ever knew and put it that way round! The key issue is how we deal with the problem.

Conservative Members say that the European working time directive is the issue, but they have always been a bit confused about it on the Opposition Benches—perhaps it is the word "European" that explains their opposition to it. When they were in government under an employment Minister called Mr. Portillo, they got confused and thought that it was part of the social contract—

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Photo of Alan Johnson Alan Johnson The Secretary of State for Health

The social chapter—the hon. Gentleman is right to correct me, as the social contract is something completely different, which I well remember from the early 1970s. Let us be clear: the Tories got confused about the social chapter and the British taxpayer— [Interruption.] I am asked what this has got to do with it, but the European working time directive is mentioned in the motion. They got confused and spent thousands of millions of taxpayers' money, fighting a case in the European courts, which they lost because it is a health and safety measure and does not come under the social chapter or the social contract.

I was also asked in an earlier intervention about the opt-out, which the British Government intend to maintain. In co-decision with the European Parliament, we will maintain the opt-out as we have done for 12 years. The fact is that that argument—Opposition Members should understand this—will make not the slightest difference to the NHS. There is a separate agreement for junior doctors. We have decided—I would be surprised if anyone took a different view—that the national health service will have a 48-hour working week with no opt-out. The reason for that is that with the rotas and flexibility necessary in the NHS, the system cannot be run effectively if we are constantly depending on who opts in or out. Whereas individual doctors can, we are implementing this by having a 48-hour week, which will come about on 1 August 2009.

That is not to say that we do not recognise the argument about doctors flogging themselves to death. Tony Baldry, who is no longer in his place, raised this issue and said that he is kept awake at night worrying about the working time directive. The point of that directive was to stop clinicians staying awake all night because they were obliged to be at work for horrendously long hours, which adversely affected the quality of care provided.

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Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

The Secretary of State lectures us about the working time directive, but ignores the point that really matters. There was an agreement in the Council of Ministers to change the definition of "resident on call" so that it related to time spent actually working at night rather than all the time when one is resident but asleep. That is a critical issue, so will the Secretary of State explain why Labour Members of the European Parliament voted against the Council of Ministers' compromise, the purpose of which was to enable us to interpret "resident on call" in a way that worked for the national health service?

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Photo of Alan Johnson Alan Johnson The Secretary of State for Health

I am raising this because I was asked about the opt-out in an earlier intervention, but the opt-out is not the issue. What the hon. Gentleman mentions is, of course, an issue. It is a crucial issue in order to ensure that the agreement we struck with the Commission, after a long period of virtually hand-to-hand fighting, was maintained. [Interruption.] It is a co-decision. I am not sure how Conservative MEPs voted on the issue, but it is a co-decision, as I said. The decision is taken based on decisions in Parliament, but it has to be agreed with the Commission and with Ministers.

The working time directive was first introduced in 1998, the NHS has made excellent progress in meeting its terms and the majority of NHS services—the vast majority of them—already meet the 48-hour requirement, which will come into force in August 2009. There will always be parts of the service where this is particularly challenging, and we will work with the British Medical Association and the Royal Colleges to address those areas over the next few months. [Interruption.] Incidentally, the BMA is fierce in protecting the safeguard of the 48-hour week and would not appreciate any— [Interruption.] That is a relief— [Interruption.]

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Photo of Sylvia Heal Sylvia Heal Deputy Speaker

Order. If hon. Members wish to make a point, I think that they know the parliamentary procedures for them to do so.

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Photo of Alan Johnson Alan Johnson The Secretary of State for Health

I apologise for encouraging them, Madam Deputy Speaker.

The hon. Member for South Cambridgeshire is wrong to say that we are not prioritising the improvement of trauma care. We believe trauma care needs to be recognised as a specialist form of medicine. Patients who are severely and critically injured need the expertise of many specialist professionals—from critical care doctors to neuro-surgeons. Just as we have improved specialist care for conditions such as stroke, so we will also improve trauma care. That is why, as part of my noble Friend Lord Darzi's review of the NHS, every strategic health authority set out how they would improve the provision of trauma care—most by setting up specialist centres in trauma care.

The hon. Member for South Cambridgeshire asked in his speech and his motion what happened to the report and why there was nothing in the Darzi review, save for the three-digit number, about urgent care. What he fails to recognise is that the Darzi report incorporated all nine SHAs' visions for the future in their regions, which were worked out with their clinicians, their patient groups and the public. The final report published in July last year was an implementing document or an overview so that all of that could be put in place.

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Photo of Sandra Gidley Sandra Gidley Shadow Health Minister

It was a useful idea to have all these workstreams at each SHA level, but I am somewhat confused by the acute care pathway reports for the South Central SHA, as the chair is a consultant in the care of the elderly. Many would have had more faith in the process if it had been chaired by somebody with expertise in trauma care. How can the public and people working in the sector who are trying to drive change have full confidence in the process if the team is not as appropriate as it should be?

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Photo of Alan Johnson Alan Johnson The Secretary of State for Health

I do not think that the process should be judged by the profession of the person chairing it. Someone has to chair these groups and in this case it was necessary to look at clinical services right across the patch. The point is that trauma was a priority in every SHA report. They made it a priority in the regions. People cannot accuse us of being top-down and top-heavy and tell us we should have local involvement, and then complain when the Darzi review is implemented in that very way—I am not saying Sandra Gidley was complaining, but Conservative Members were.

The report on trauma care was published two years ago just as the Darzi review was being formulated, and the idea now is to carry forward those visions in each strategic health authority. We need someone to oversee this, however, and I can today announce that I am appointing Professor Keith Willett, chair of the British Orthopaedic Association's trauma committee and a leading international expert on fractures and trauma, to be the first national clinical director for trauma. The hon. Member for Banbury, who is not in his place, will probably know him very well because he is a leading clinician at John Radcliffe, Oxford.

I agree that the public should be given a say in how urgent and emergency care services are configured. Indeed, the next stage review sought the views of more than 40,000 people, and asked them specifically what improvements they wanted to see in urgent and emergency care. Clinicians used the views expressed by patients to make their recommendations for what should happen in each region.

I join the hon. Member for South Cambridgeshire in his praise for the contribution made by community first responders. They play a vital role in improving responses to 999 calls in many parts of the country and in supporting ambulance services. They are not, however, a substitute for an emergency ambulance response. I am delighted that the Opposition are favourably disposed to potential plans to bring in a new, single digit number to access urgent and emergency care services. As my noble Friend Lord Darzi has pointed out, this would provide a quick, convenient way for people to find out about local urgent care services, particularly out of hours or away from home, and we will be consulting on this proposal in due course.

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Photo of Graham Stuart Graham Stuart Conservative, Beverley and Holderness

Yorkshire ambulance service, with which the Secretary of State will be familiar, provides data by local authority area at present; it does not do so on a ward-by-ward basis. Given that there is concern in rural communities about differences in performance between wards, will the Secretary of State encourage ambulance trusts around the country to provide data down to ward level so that we have a clearer picture?

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Photo of Alan Johnson Alan Johnson The Secretary of State for Health

That point is worth looking into, and I will do so. We currently have the best performance ever from our NHS ambulance service, and we should include it in our congratulations.

The hon. Member for South Cambridgeshire asked us to publish the urgent care strategy, and I dealt with that in mentioning the strategic health authorities. [Interruption.] I accept that my responses to the points that have been raised are of varying quality. It is sensible that SHAs should carry forward their vision, and we should help them and fund them to do that.

Over the past 12 years, there have been real—indeed, dramatic—improvements in patient care. Patients no longer have to wait years for treatment after referral; at most they have to wait 18 weeks, and the average wait is about eight weeks. The vast majority of patients wait for less than four hours in accident and emergency. Let me put in perspective what this means for patients. A doctor I spoke to recently told me about the accident and emergency department in which he worked in 1995, where waits of 12 hours or more were so frequent that patients were asked for two meal choices when they arrived. Sheets were taped across the corridor to create makeshift wards. He now works in a hospital in the same area where accident and emergency patients are treated on average in just over an hour.

The measures we have taken over the past 12 years have dramatically improved the quality of urgent and emergency care, as the Opposition motion recognises. The abolition of long waits for treatment is one of the NHS's finest achievements. Greater investment, more staff, better planning and strong leadership have transformed urgent and emergency care services for patients, and I commend the amendment to the House.

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Photo of Sandra Gidley Sandra Gidley Shadow Health Minister 1:44 pm, 21st January 2009

I welcome this debate. When I first read the Conservative motion, I thought it was a bit of a hotch-potch: half of it nobody could disagree with—it praises everyone under the sun, and there is nothing wrong in that—but the rest of it seemed like the product of a brainstorm, with references to almost anything that might be remotely related to emergency and urgent care. However, although some of those topics have not been pursued in the debate so far, the Conservatives have highlighted a very important subject.

Mr. Lansley took the Secretary of State to task because the Government's amendment mentions out-of-hours care, but I think the changes in the provision of that care have had an impact on emergency and urgent care, so it is probably worth mentioning some of them. The Government have done many things to improve care for patients, but they would probably acknowledge quietly that one of their biggest mistakes was to take responsibility for out-of-hours care away from GPs and put it in the hands of the primary care trusts. As a result, the GPs were only responsible for the core hours from Monday to Friday. In some areas, GPs wanted to provide weekend care, particularly if they had a high commuter base, but that was actively discouraged by PCTs. The costs shot through the roof, and in some places the out-of-hours services were introduced hurriedly—to describe what was on offer in many areas of the country as an "unmitigated disaster" is putting it quite mildly. Many people waited more than four hours for a GP to arrive. In my area, we are flying in doctors from various parts of the European Union. A lot of them are German. I have no problem with German doctors; they are all very nice, and people generally had a positive experience. However, those doctors did not understand local services and a number of significant problems arose; if they wanted to section somebody, for example, they did not understand the UK law and procedures governing that decision.

The number of people resorting to calling an ambulance also markedly increased. It is perfectly understandable that a concerned patient might do that if the out-of-hours service is not responding and they are not getting the reassurance they need. We should not criticise patients for doing that.

The Government amendment applauds the increase in GP opening hours. I concede that that may have enhanced choice, but I do not think it has improved access to urgent care because many people are making routine appointments for those extra hours. It is important to consider what urgent care actually is, and it is worth posing a couple of fundamental questions. How does the patient know whether their symptoms are the sign of something serious—whether they can wait to have them checked out, or if they should be making a fuss about being seen? It is clear that different patients respond in different ways. Most GPs will have their regular complainers, but in the days when GPs knew their patients—I hate to say "the good old days", because I am not sure they were good in all respects—the GP was often able to make a value judgment. They could say, "I saw Mrs. X only last week. I know her quite well, and I think reassurance will go a long way in this case." In the hands of a doctor who does not understand Mrs. X, however, more resources might be used because they do not know the background and personality of the patient and they will therefore treat them on a more precautionary basis.

I suspect that most Members present will have been out with an on-duty ambulance crew. From witnessing them calling on people, it is obvious that there is a wide range of differing attitudes as to the circumstances in which it is appropriate to call the ambulance service out. One of my first pieces of casework when elected as an MP related to an ambulance that did not arrive to a call from a rural setting, and I was horrified to find out that ambulance crews were often having to deal with very trivial cases. Although the ambulance service does a wonderful job, it does not need to do much of what it does. Every time somebody with a trivial complaint calls out an ambulance, they are potentially endangering the life of somebody else. That risk is not communicated often enough.

The first point of call for people who are ill is usually the surgery. Even if it is closed, they often think of calling their GP, and, in many cases, the call is diverted to the appropriate out-of-hours service. That is what one would expect, but the recent Healthcare Commission report showed that in a significant number of cases—I cannot recall the statistic off the top of my head—the relevant information was not communicated. That resulted in the patient either having to dial somewhere else or thinking that they did not want to speak to a doctor who they did not know and wondering whether they had any other options. Some people will look at various websites for advice, whereas others will go to their nearest pharmacy. Accessing NHS Direct, either on the web or by phone, is a popular choice. Other people will choose to use a walk-in centre or out-of-hours care, or they may call an ambulance because they do not know what to do and are worried.

I welcome the move towards having a single contact number, but I make a plea that during the consultation we examine what has happened when the police and other bodies have introduced such a number. Often, what has happened is that all the other numbers have gradually been withdrawn and people have not then been able to choose to ring the department that they want directly; they have always then had to go through a central switchboard, and often they have not been able to ring their local provider and speak to the person whom they know. To be fair to the police, locally they have got much more sophisticated about this and have found other ways of getting around the system. People who know whom they wish to ring find it frustrating to have to go through a bureaucratic telephone triage service—to go somewhere else. By all means, let us have a single point of contact, but if someone knows whom they want to contact, it should be easy for them to do so—there should be no barrier. So, there are pluses and minuses to the proposal.

I wish to discuss the strain on ambulance services. As a result of inappropriate calls, the London ambulance service, among others, introduced a clinical telephone advice team to advise callers who had less serious conditions—the team made a point of ringing such people back. During 2007-08, the London team handled more than 58,000 calls, and analysis showed that, over the year, that freed-up the equivalent of 35,383 ambulances for patients who needed them more. Not every ambulance trust has that sort of system in place, despite facing similar pressures, so it may be worth considering whether that is best practice. Although different areas rightly provide different solutions, it is also worth examining things that work well elsewhere.

This might be an appropriate time briefly to mention ambulance response times. The most commonly known target is to reach 75 per cent. of category A life-threatening situations within eight minutes of the call. I have never been able to establish why eight minutes was decided as the crucial figure or why 75 per cent. is acceptable—perhaps the Secretary of State could enlighten me—but there are added pressures this year. In previous years, some ambulance trusts have been accused, rightly or wrongly, of manipulating the time when the clock started in order to improve their results. Now, so that there is no dispute, the clock starts ticking as soon as the call connects and there is thus a level playing field.

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Photo of Simon Burns Simon Burns Opposition Whip (Commons)

If the hon. Lady is correct in saying that the clock starts when the call commences—presumably we are talking about the call from the member of the public to the ambulance service—how can there be a level playing field, given that some people may take three minutes to explain the problem about which they are ringing whereas others may take just half a minute?

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Photo of Sandra Gidley Sandra Gidley Shadow Health Minister

I do not think that the people who take three minutes are predominantly to be found in Chelmsford and the people who take half a minute are predominantly to be found in another area of the country; the variation will be found across the country. I do not really understand the point that the hon. Gentleman is making; I think it is a rather trivial one.

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Photo of Simon Burns Simon Burns Opposition Whip (Commons)

No, it is not a trivial point at all—

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Photo of Sylvia Heal Sylvia Heal Deputy Speaker

Order. Would the hon. Lady like to give way?

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Photo of Sandra Gidley Sandra Gidley Shadow Health Minister

No, I will continue with the point that I was intending to raise. Just before Christmas, the pressures to which allusion has been made—I will not repeat them—meant that the London ambulance service had its busiest week in history; ambulance staff responded to 20,939 emergency incidents across the capital in the seven days up to 14 December. That was an increase of 8 per cent. on the average for the previous four weeks. The pressure was intensified by the high percentage of calls that were initially treated as category A situations. There is a growing sense of disquiet in some quarters about that fact that canny members of the public know that if they mention chest pain, an ambulance will be sent very quickly. There is a need for a retrospective review as to whether calls are being categorised correctly. No trust wants to gamble with people's lives, so perhaps this is the way we have to do things, but the system has been in place for some years and it is probably time to change it.

Just after Christmas, particular problems were encountered in Hampshire. The Southern Daily Echo cited a story of a pensioner who was left waiting 70 minutes for an ambulance when she suffered a suspected broken leg, having slipped on an icy pavement. The temperature was below zero, the lady was 85 years old and, apparently, it did not require a paramedic to see that her leg was broken because it was at a fairly unnatural angle. The South Central ambulance service was unable to provide a comment at the time of the report.

Only two days later, another serious incident took place. A seriously injured policeman had to be rushed to hospital in a fire engine because no ambulance was available. A special equipment unit was transformed into the makeshift ambulance because the patient needed urgent medical treatment following a crash in Southampton. A paramedic had arrived on the scene, as had a BASICS—British Association for Immediate Care—doctor, but the ambulance response was not forthcoming. There are always times when unusual demand is difficult to cover, but in an emergency a situation such as I have described is of concern.

I wish to discuss BASICS doctors, because they have not been mentioned in this debate and they are an often-forgotten part of the response to major trauma. Dr. Phil Hyde, a constituent of mine, approached me—

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Photo of Sandra Gidley Sandra Gidley Shadow Health Minister

This could be a debate that we have had in Westminster Hall, but as some hon. Members were not present for that, it is worth repeating things. In addition, some of the points from the Westminster Hall debate were not addressed. If the hon. Gentleman is saying that because we had a debate on Equitable Life, we do not need to discuss it again, that is fine, but I contend that if a subject is important, it is worth discussing on repeated occasions.

Prior to the meeting with my constituent, I had no inkling of the fact that if I were seriously injured in a road accident, my prognosis would be severely affected by whether or not a voluntary doctor was available. Many such doctors work full-time in the NHS, often in disciplines such as anaesthetics and sometimes in emergency care. I had always thought it was like "Casualty"—once a year, usually on the Christmas special, there is a major incident and all the casualty doctors go to the scene of the accident—but, in real life, that is not what happens in most parts of the country. This matter is important because of what is said in the often-overlooked 2007 report by the National Confidential Enquiry into Patient Outcome and Death, entitled "Trauma, Who Cares?". It concluded that the current structure of pre-hospital management is insufficient to meet the needs of severely injured patients. There is a high incidence of failed intubation and of people arriving at hospital with a partially or completely obstructed airway. The report continued:

"Change is urgently required to provide a system that reliably provides a clear airway with good oxygenation and control of ventilation. This may be through the provision of personnel with the ability to provide anaesthesia and intubation in the prehospital phase, or the use of alternative airway devices."

The report said that ambulance trusts must address that.

The stark reality is that patients who die from severe injuries often do so within the first hour after an accident, and in the UK that time has usually passed before the patient reaches hospital, and that is on the assumption that the ambulance and paramedic response to the scene is normal. If a BASICS doctor arrives, they can stabilise the patient at the scene of the accident and decide the most appropriate destination for that person. It must be borne in mind that, because of centralisation of services and major trauma centres, the destination is not always the nearest hospital. BASICS doctors therefore provide a benefit in terms of the appropriate care.

During the Westminster Hall debate, the Minister said that he would shortly have a meeting with the people responsible for producing the report from National Confidential Enquiry into Patient Outcome and Death, and that he would raise some of the issues that were mentioned during the debate. It would be useful if he could update us on that. The BASICS service is voluntary and often funds its own equipment because doctors do not have enough time, after doing their full 48 hours in the NHS, to provide the emergency service and carry out fundraising.

Some parts of the country, such as Sunderland, have focused on trauma injuries and significantly reduced the death rate from major trauma from the national average of 5.8 per cent. to 2.9 per cent., and have introduced new response teams, which seem to be having an effect.

Many parts of the country rely on air ambulances, and it is frustrating that the running costs are often funded by local donations and voluntary contributions. I am a little worried about that. Although in my neck of the woods in Hampshire the air ambulance service is relatively new and is given the current financial pressures well supported at the moment, there is concern that funding for all charities may decline. The South Central Ambulance Service NHS Trust told me that it pays for the clinical response, but not for the helicopter, which is funded by a well organised group. That was a strange response, because it does not say that it will provide paramedics but not fund the costs of ordinary ambulances. I am not sure of the significance of different modes of transport. What consideration has the Minister given to charitable funding of air ambulances, and does he believe that that is sustainable in the long term?

Last year, the Healthcare Commission's report, "Not just a matter of time", reviewed urgent and emergency care. It concluded that most sectors performed well against national standards for access to services, but it found that performance was more varied in services that receive less national attention. That is no great surprise, and Members of Parliament are always highlighting those services. The overall stats show that the response to category A calls was generally good. That is where the main focus falls, and there is not a lot of room for argument, but one should note that those results are given by trust. I made a freedom of information request to find out the response times on a ward-by- ward basis in my constituency. Lo and behold, those parts of my constituency in Southampton received an 80 or 85 per cent. response, which is excellent for people who live in the big city, but in some of my more rural wards an ambulance had never reached an emergency within eight minutes. That is not something to shout about, because it is inequitable—indeed, it is the reverse of the inequality usually seen in the health service, because those who are suffering are not those who live in urban areas, but who perhaps live in more affluent areas. Does the Minister have any plans to refine the targets so that it is realistic to expect an ambulance to reach people within eight minutes, wherever they live, not just in the large urban conurbations?

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Photo of Nadine Dorries Nadine Dorries Conservative, Mid Bedfordshire

Would the hon. Lady be satisfied with an assurance that an ambulance would try to get to those who need it? It could be trying for hours. Is that the sort of reassurance that she is looking for?

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Photo of Sandra Gidley Sandra Gidley Shadow Health Minister

Perhaps my choice of words was unfortunate, but at the moment the response times are based on large geographical areas, so if a 75 per cent. rating is achieved throughout a trust area, the target is reached, but there is no subdivision that provides that targets must be reached in all areas. It is clear that some areas do not receive the service that they should, and I suggest that the hon. Lady makes a freedom of information request to her ambulance trust. I had always suspected that my rural areas received a less than good service, but the results are much worse than I had anticipated, and almost a whole borough council area was missing the target. Surely there is something wrong with such a response time.

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Photo of Simon Burns Simon Burns Opposition Whip (Commons)

May I try again on the targets? Despite the look on the hon. Lady's face, I think that she misunderstood my point. She suggested that the eight minutes starts at the moment the call is taken, but if someone is agitated, they may take three minutes to explain why they need an ambulance, and someone who is less agitated or more articulate may take 30 seconds. Surely a target of eight minutes is unfair if the starting time for monitoring purposes is the moment that the call starts. That is all I was trying to say.

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Photo of Sandra Gidley Sandra Gidley Shadow Health Minister

The level playing field to which I referred was between trusts. There has been significant variation in the way in which response times were monitored. For example, some started the clock when a call first came into the centre, others started it when the call was answered, and so on. I understand the hon. Gentleman's point, but if trusts are given flexibility to make a value decision on how to obtain the correct information, that is open to manipulation. All the evidence that I have seen shows that trusts consider every step of the pathway to try to make their figures look better and to hit the target. I do not blame them, because if they achieve their target, they are not subject to greater scrutiny, but there is not a quick, easy and simple way of taking that measurement out of the system and retaining equity in the way in which response times are compared with other trusts. I sympathise with the hon. Gentleman's point, but there is no quick and easy answer.

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Photo of Sandra Gidley Sandra Gidley Shadow Health Minister

If the hon. Gentleman does have a quick and easy answer, it is probably not appropriate for an intervention. He might want to stand up and make some comments later, but I feel that I should finish my speech so that other hon. Members can speak.

The response to category A calls is good, but there is much more variation between the targets and the responses in the case of other urgent calls. The Healthcare Commission found that in some areas fewer than 80 per cent. of ambulances arrive within the target time. On arrival in hospital, there are significant variations in the proportion of patients seen by a doctor or nurse within the first hour after arrival. That figure varied from 40 to 100 per cent. Clearly, there is work to be done.

There is also evidence of poor compliance with guidance on access to medication from out-of-hours GP services. Although that might not be seen as urgent care, if a patient is in pain or something like that, the care is certainly urgent to them. Concerns were also raised that suggested that many people were either unaware of the full range of urgent and emergency care services or were unsure about how and when to use them, which brings us back to the issue of the single contact number. Most importantly, the need to improve the way in which the services work together was highlighted.

Data-sharing is poor and PCT commissioning was highlighted as a concern. A survey produced last week showed that patients rate their care highly but raise concerns about pain control and information given on discharge. That takes us back to the mention of data sharing in the earlier reports. The people who are providing emergency care often do not have sufficient information about the patient. If somebody has been in accident and emergency, or has even been treated in out-of-hours care services, the relevant information is not always relayed back to the GP in as timely a fashion as it could be. Perhaps the Minister could tell us when decisions will be made about information-sharing with regard to the NHS IT project. There is a lot of healthy debate about what level of information can be accessed by whom, but it could be crucial to outcomes in those particular cases.

I want to end by making a comment that many hon. Members start their speeches with: I thank those who do their best to provide an emergency service, whether they are paid workers or volunteers such as community first responders or BASICS doctors. We owe it to all those people to ensure that attention is given to ensuring that people have the best possible outcome in the case of emergencies and that the PCTs ensure that funding streams are adequate. The problem with this area of medicine is that most people are grateful to have received urgent care, and they are often so pleased to be better and to have their problems sorted that they do not take the time to step back and ask whether their outcome could have been improved or whether their quality of life could have been different had a doctor been on the scene. Staff want to do better, but in many cases they are hampered by a lack of attention to best practice and, in some cases, sadly, by a lack of funding.

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Several hon. Members:

rose —

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Photo of Sylvia Heal Sylvia Heal Deputy Speaker

Order. I remind all right hon. and hon. Members that Mr. Speaker has imposed a 15-minute time limit on contributions from Back Benchers.

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Photo of Joan Ryan Joan Ryan Labour, Enfield North 2:13 pm, 21st January 2009

First, let me pay tribute to the hospital in my constituency, Chase Farm hospital. It has been much mentioned in this Chamber over past years and will surely continue to be mentioned in time to come.

I was at the hospital just over two weeks ago on a Saturday afternoon with my four-year-old granddaughter, who had injured her hand. She is recovering. When one is interacting with the NHS at the point of an emergency, it really comes into its own. It is fantastic. Within five minutes of walking into the hospital, my granddaughter was assessed and in less than two hours she was treated. She was then referred to another hospital that had a hand specialist. That is an important point, because when we talk about access to emergency departments and urgent care it is important to remember that accident and emergency departments do not deal with everything. A patient who goes into an accident and emergency department might be referred to another one or might be assessed in the ambulance by the paramedics and taken to a specialist hospital. The idea that there are not specialist hospitals or that accident and emergencies deal with everything all the time is a false assumption.

That little girl saw a hand specialist at 8.30 on a Saturday night. By the Monday morning, she had had a small operation and I am pleased to report that she is recovering well. I think that that is a model story and I do not think that it is an unusual one. I base my opinion not just on that story but on the way in which Chase Farm hospital has responded to the pressures of winter and those over the Christmas period. The staff have worked very hard. Morale is sometimes low, because of the proposals to do with the hospital, but the staff have responded magnificently in recent times to the pressures that they are under and I pay tribute to them.

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Photo of Joan Ryan Joan Ryan Labour, Enfield North

I will not, because I have only 15 minutes. I am sorry that I cannot give way, but time is pressing.

I want to go back a little to the remark made by Mr. Lansley that we should stick in this century. I would like to point out that we are only nine years into this century, which is not a lot. The idea that history has no impact on the present or future is clearly nonsense.

In 1997, when I was elected MP for Enfield, North, through the doors of my advice surgery came many people, often elderly people, who had waited in pain, for almost two years for a hip replacement. That pain not only made the quality of their lives appalling but, even after the operation, undermined their health. Lots of people came to my surgery who had waited considerable amounts of time for cataract removal. The wait significantly affected their ability to engage in life and to be independent. I no longer have anybody coming through my surgery doors with those problems. That is not to say that nobody comes through the door with issues about the NHS, but they do not come to see me with those problems. The 18-week wait is a significant gain for the people who depend on the NHS.

All those factors affect urgent and emergency care. If people are dealt with early in the onset of any illness or disease, they are much more likely to make a good recovery and much less likely to present at an emergency department at some point in the future. The same is true if there is good, accessible, available primary care, as people are then much less likely to need to present at an accident and emergency department or to need urgent care.

In Enfield, we very much need the primary care strategy that our primary care trust is planning. I worry that the Conservative policy of deriding and undermining confidence in the notion of polyclinics will damage the ability to put in place a good primary care strategy. Let me give an example of what that strategy means to us in Enfield. We know now that we are getting a health centre in the Enfield Lock area. Professor Sir George Alberti came to Enfield, and he said, "You need an improvement in access to primary care in the north-east of your constituency." That is now happening. The plan is that we are to have a big health centre with an independent living facility attached to a community school. It will provide a first-class service to the people of Enfield Lock, Enfield Highway and north-east Enfield. That will reduce the number of people who have to leave the area and go to accident and emergency centres with problems that local GPs or walk-in centres can deal with. The health centre will mean that people have much more access to local primary care.

The primary care strategy will have another impact in Enfield, North. Although it will not be built in the next two or three years, a polyclinic is planned for the town centre. Many GPs practise in that area, so it is nonsense to say that people will have to travel vast distances to get to their doctor if a polyclinic is set up. It is a densely populated, town-centre area, so there is no need to fear that. The polyclinic will have longer opening hours, and people will have much greater access to a greater range of specialist GPs. Moreover, the centre's technological diagnostic resources will mean that people will not have to wait for a hospital appointment to get the same service.

The primary care strategy for Enfield, North means that there will be a polyclinic in the town centre and a health centre in north-east Enfield. Add to that the fact that people will have access to the Forest road health centre just over the border in Edmonton and to the walk-in centre at the North Middlesex hospital, and it is clear that the strategy will be a huge improvement.

The result will be that people will have access to their local health centre and then, if they need it, they will be able to go to the much larger health centre set-up that is sometimes known as a polyclinic. Beyond that, they will have the walk-in centres, local accident and emergency facilities, and the trauma centre provided by the North Middlesex hospital. At local level, the primary care strategy will really serve the needs of people living in Enfield. I worry that some of the propaganda pumped out by the Opposition encourages people to fear any kind of change at all. It undermines their confidence in the excellent service provided by the NHS, and in what is very necessary change to primary care provision.

I want to say a few words about Chase Farm hospital. I am pleased to have the opportunity to do so as I have spoken about it many times, both in this Chamber and in Westminster Hall. Indeed, Mr. Burrowes had an Adjournment debate on the issue only last week. I attended and intervened, and my hon. Friend the Minister is well aware of my views.

I do not oppose change, but it is important that local people are listened to and, without exception, the people and elected representatives in my constituency do not support the proposed changes at Chase Farm hospital. However, that needs to be put in context, and to that end the past is important once again. For the first time in 20 years, the people in my area can be confident that a hospital will be maintained on the Chase Farm site. We have managed to achieve some real gains, including ensuring a secure future for the hospital, and I advise anyone who doubts that—including Opposition Members—to compare local Conservative literature with the hospital trust's original proposals. One of those proposals was to close the hospital altogether, so it is clear that our success in saving it is a real achievement.

The second gain is that there will be an expansion in planned surgery at Chase Farm hospital. That protects the heart of the hospital—its wards and operating theatres—and so is very important to people in Enfield, especially those elderly people who are much more likely to need orthopaedic and other operations. It is very important that they be able to go into hospital locally.

We have also gained some local accident and emergency services. The original proposals put forward what might be called a "hot-cold" model, under which Chase Farm would provide only elective—that is, planned—surgery and nothing else. We have managed to get rid of that proposal, which is a gain in itself. In addition, and with the support of the Minister, we have also managed to achieve agreement about having a midwife-led birthing unit, so that Enfield babies can continue to be born at Chase Farm.

I am not in favour of any reduction of service at Chase Farm hospital, but it is important to understand the context. I shall continue to campaign and do everything that I can to maintain the present level of service.

The motion refers to a report from the College of Emergency Medicine, but the interpretation offered by the hon. Member for South Cambridgeshire was inaccurate. In an intervention, he spoke about distances, but in that respect the report does not help the argument about Chase Farm hospital. I have asked the Minister to look at the matter again, given the significant increases in birth rate and the elderly population. The report notes:

"There is no single solution to the reorganisation of emergency care. In urban areas where" emergency departments

"are close together (less than 10 km apart) there may be advantages to amalgamating services".

That would not help our argument, as Chase Farm hospital is 9.43 km from North Middlesex hospital, and 10.48 km from Barnet hospital. Therefore, the report does not make the across-the-board point that the hon. Gentleman imagines. It might be more applicable in rural areas, but I do not know, as I do not represent a rural area. It certainly has very little application in my area.

The report says that each case must be taken on its merits. I agree: I have presented the case for Chase Farm hospital and will continue to do so, but I will not accept that the NHS is almost no better than it was in 1997, as it has improved significantly. There has been a huge step change, and it is time that people gave that more credit, rather than always talking the service down and looking for the negative.

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Photo of Simon Burns Simon Burns Opposition Whip (Commons) 2:28 pm, 21st January 2009

I am delighted that we have the opportunity today to debate emergency and urgent care in the NHS. I fully support the motion tabled by my right hon. Friend the Leader of the Opposition and our Front-Bench team, but—perhaps unusually—I can also support the beginning of the Government's amendment.

Like my hon. Friend Mr. Lansley—to be fair, I must add that the Secretary of State expressed the same sentiments in his opening remarks—I fully support and admire the people who work in the NHS. Without all the doctors, nurses, consultants and ancillary workers—who too often are not mentioned—we would not have a national health service. They are there, day in and day out, often without much praise or notice, delivering health care to our constituents and to ourselves.

In my brief comments I shall discuss accident and emergency services, which all too often work under tremendous stress and strain. For many members of the population, that is the first point of contact with the local hospital. The problems that A and E services face have been exacerbated—certainly in my area, mid-Essex—by the dramatic increase in the number of people turning up or being admitted to A and E as a result of drug or alcohol-related abuse. That is a growing problem.

The Minister of State, Department of Health, Mr. Bradshaw, who is on the Front Bench now, answered a written question from me yesterday. His reply showed that in 2002-03 there were just over 2,500 admissions to Broomfield hospital in Chelmsford as a result of drug or alcohol-related problems. By 2005-06 that had increased to just over 4,000 episodes. Fortunately, the next year, 2006-07—the last year for which figures are available—the level had marginally dropped to just under 4,000, but the figures show the dramatic increase in that problem, arising from the increased incidence of binge drinking and irresponsible drinking and behaviour in our town centres. The problem is spreading to our rural areas as a result of abuse, a misunderstanding of the dangers of alcohol consumption, and the failure to adopt a responsible and mature attitude towards it.

The knock-on effect is the strain that that puts on A and E staff, not only because of the medical problems emanating from the abuse that brings people to A and E, but sadly, because of the behaviour of some of the patients resulting from the state of mind that they are in. If someone has been brought into A and E by friends who have been out with them, the friends, too, may be suffering the effects of alcohol abuse, which exacerbates the problem and the way in which they interrelate with staff. The patience and the behaviour of such people are not as they would be if they were sober. That is unacceptable and needs to be addressed more strenuously than it is at present, although I accept that most hospitals are adopting zero tolerance of bad and antisocial behaviour.

A similar problem, although it does not arise directly from alcohol abuse, is violent and aggressive behaviour towards staff. It is incredible that people whose entire raison d'être and work is to relieve pain, remedy sickness and reduce the suffering that results from illness should be verbally or physically abused for their pains. It is a sad reflection of the society in which we live.

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Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

My hon. Friend raises an important point. He will know, as I do from spending Friday and Saturday evenings with accident and emergency department staff, how difficult that can be for them. Things should not be that way. Will he join me in commending the action taken by, for example, the Queen's medical centre in Nottingham? Instead of sitting in the accident and emergency department waiting for cases to be brought to them, often causing considerable trouble in the department for other people attending and needing care, A and E staff go out and set up field hospitals in the centre of Nottingham, to take care to the place where trouble is predicted. That does not mean that they want trouble, but it shows that they are thinking proactively about how to manage care more effectively. There is the additional benefit that large numbers of ambulances are not tied up in the course of an evening.

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Photo of Simon Burns Simon Burns Opposition Whip (Commons)

I am extremely grateful to my hon. Friend for an important and interesting example of a proactive service. The NHS in other parts of the country should look at the experience in Nottingham to see whether they could learn and benefit from setting up a proactive service themselves. I strongly believe that there is a positive future role for A and E departments throughout the country to learn from that experience and seek to replicate it. As with preventive medicine, it is important for the health service to be proactive. In the longer term that pays handsome dividends.

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Photo of Nicholas Soames Nicholas Soames Conservative, Mid Sussex

Will my hon. Friend confirm that the increased work load comes on top of substantial increases in the work load caused by respiratory infections in elderly people, flu and the norovirus, which have placed an immense added responsibility on accident and emergency departments? By and large they have coped magnificently.

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Photo of Simon Burns Simon Burns Opposition Whip (Commons)

My hon. Friend is right. He highlights another problem that has developed in the health service. It was always assumed that the pressure points of increased activity occurred in the winter months when it was coldest or iciest. In the past few years we have seen that those pressure points in the NHS are no longer restricted to the traditional winter months when the weather is particularly bad. In my local hospital, Broomfield, the pressure was worse in June last year than it had been in the worst winter month. The health service has had to adapt to changing circumstances, and the old accepted problems of winter pressures are being extended, for other reasons, to other months, putting extra pressure on resources and staff.

There is a further issue facing accident and emergency services which it might not be tactful to discuss. The NHS must be tough and not only accept that there is a problem, but be brave enough to try to do something about it. Sadly, part of the population go to accident and emergency for treatment as a first resort, when their complaint is in no way related to an accident or emergency. A and E should not be their first port of call. They should use NHS Direct or contact their GP or, in some cases, their pharmacist. If people misdiagnose themselves and misdirect themselves to A and E for treatment, that puts excessive demands on the health service and on other patients waiting for A and E treatment, who may have far more serious complaints or conditions that warrant their being there in the first place. More must be done to educate people and to explain why they should not trot along to A and E simply because it is more convenient for them.

On the four-hour waiting time limit, four hours may be a relatively short time compared to the length of time that some people had to wait in the past, but it is still quite a long time to hang around. For someone who goes to A and E with a medical complaint that is acutely painful, even if it is not as medically serious as the pain that the individual is suffering, four hours can seem a very long time. My A and E at Broomfield reflects the situation nationally. We have seen a significant increase in the number of people attending A and E in recent years. In the year up to December 2007 there were 5,469 attendances at A and E. The next year, ending December 2008, the figure was up to 5,783. The target that 98 per cent. of people should wait less than four hours is being met in my A and E department. The latest figures for 2007-08 show that it achieved 98.3 per cent. I accept that that is of little comfort to the 1.7 per cent. who are not included in those figures.

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Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

I am sorry to interrupt my hon. Friend, who is making an important point, but it might be of interest to him and to the House to know that the NHS information centre this morning published an analysis of the data from hospital episode statistics, which shows that 4.1 per cent. of people who attended A and E departments had a recorded time for arrival but no recorded time for departure. That is the equivalent of more than half a million patients a year who appear simply to drop out of the statistics. That is quite separate from the point about 98 per cent.

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Photo of Simon Burns Simon Burns Opposition Whip (Commons)

Very much so. It would be interesting to hear what the Minister has to say about that. There is another discrepancy, in that the figure that I have given for my local hospital for the meeting of the four-hour target, except for those 1.7 per cent., looks encouraging because it is slightly above what it should be, but the Healthcare Commission recently published a survey of visitors to A and E at that hospital showing that patients' perception of the service varies radically, and, sadly, it is in the bottom 20 per cent. for patient satisfaction. The trust accepts that it is disappointed by the results and says that it is seeking to improve what it calls the patient experience as a top priority. That is important, because it means that the trust recognises that there is a perception with users that it is not as good as it should be.

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Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

My hon. Friend is being generous in giving way. It is important for us to understand exactly what is going on. The Healthcare Commission found that only 73 per cent. of people who attended A and E departments reported that they were seen and treated within four hours. It surmises that a significant number of people are being put into admission units or medical assessment units, and because those are attached to A and E they believe that they are still in A and E, whereas from the hospital's point of view the clock has stopped ticking.

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Photo of Simon Burns Simon Burns Opposition Whip (Commons)

Absolutely. I wrote to the Minister only yesterday because I have been sent a series of allegations about what happens in A and E, and I would be grateful if he would look into them.

The point is that we must move forwards. We must ensure that there are improvements so that patients not only receive the best treatment possible, which I have no doubt that they do get at my hospital, but that the waiting time is short and the triage is swift, and that they are dealt with sympathetically and treated as quickly as possible. I welcome the fact that, as a result of the Healthcare Commission survey and the trust itself examining what goes on and what should and must be done to improve the situation, the trust has been prepared to recognise that improvements need to be made and is taking initiatives.

For example, by the end of next month, a major refurbishment of the physical site of the A and E will have been completed—an important and positive step forward. On some days, a GP now works alongside the A and E team to help with patients with minor injuries and ensure that they are referred to the relevant professionals. New shift patterns have been introduced for the nursing staff to seek improvements, and a new triage system has been introduced to identify major and minor patients and ensure that they are treated more quickly within the department. A fourth A and E consultant has been recruited, and a new general manager has been appointed to oversee the work of that department.

I welcome all those initiatives. They are a positive step forward. I have no doubt that we can work together with the sole aim of improving the quality of care and the quality of the experience that patients have at A and E. Most of them are not there for the wrong reasons, but because they are in pain and probably frightened or confused because they do not know what is wrong with them, and need assistance. That is why it is so important that we ensure that we have an A and E service in our local communities that is second to none, and meets the requirements of all of our constituents.

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Photo of Richard Taylor Richard Taylor Independent, Wyre Forest 2:44 pm, 21st January 2009

By amazingly happy coincidence, the NHS constitution was published this morning, and I want to read to the House two pledges. First:

"The NHS also commits to inform you about healthcare services available to you, locally and nationally", and, secondly,

"to offer you easily accessible information to enable you to participate fully in your own healthcare decisions and to support you in making choices."

In an emergency, that pledge will be fulfilled only if there is a three-digit telephone number that everybody can contact. People know when to ring 999, but, as I have been stating since I secured an Adjournment debate on the subject in 2007, they do not know what to do in an intermediate emergency, when they have so many alternatives to consider.

The Minister, whom I am pleased to see in his place, will remember that in that July 2007 debate I drew attention to an absolute tragedy at home—the death of a little boy aged seven and a half, whose perfectly intelligent, competent parents could not work their way through the system to obtain the right care for their little boy in an area that had lost its A and E department.

In Health questions on 16 December I asked about progress in achieving a single phone number, and the Minister replied that very good progress had been made. He encouraged me to be a little more patient and await the formal announcement, so I am putting him on the spot. When will the formal announcement be made? I was horrified to hear the Secretary of State say that the Government were considering going out to consultation shortly. This is so urgent. I agree that we must get it right and that we must consider the triage system to which it is connected and what happens to the ambulance triage systems and the out-of-hours services that have their own phone numbers. I agree that the matter is complex, but consultation with those bodies should be a matter of absolute urgency and priority and should take only a short time.

Ensuring that the correct telephone numbers are available will help stressed A and E departments because people will be prevented from attending unnecessarily. The phone number must connect people to the relevant information about services available in their health community—A and E, urgent care centres, minor injuries units or out-of-hour services—which is likely to be served by a PCT and the emergency services under that PCT. Services must be networked, and everyone must know what each bit of the service can do.

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Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

I entirely agree with the hon. Gentleman and he will no doubt have noticed from what we have said over two and a half years that we very much support exactly this notion, but he has not mentioned NHS Direct. We are clearly in favour of a single national telephone number, which would replace 0845 46 47, but NHS Direct must be franchised into the same system, so that it is not separate from the system that he describes but is an integral part of it.

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Photo of Richard Taylor Richard Taylor Independent, Wyre Forest

I am grateful for that intervention; I should have mentioned NHS Direct, which I will get out of the way now. There have been many criticisms of NHS Direct; perhaps I inadvertently forgot to mention it because I have not been very impressed by it. According to reports, it refers on many more cases than it solves.

The next thing that I want to plug, and I have done so before, is an effective, excellent trialled triage system that is ready and waiting to be taken up. The Department of Health initiative, NHS pathways, offers a high-class computer software system for triaging. Work on the initiative has been going on a long time, but announcements on its progress seem to have disappeared. Nearly two years ago, the North East Ambulance Trust conducted a successful trial of the system.

Like most hon. Members, I browse on Google a good bit of the time; googling "NHS pathways" tells me that it has won awards—a FileMaker Cube award in 2008 and the British Telecom e-health insider award as the health care IM & T team of the year for 2008. The chair of the independent panel judging for that latter award said that NHS pathways was "an impressive piece of software" that was already delivering "gains" where it was in use. He added:

"Getting patients to the right place in these circumstances saves lives and stops precious resources being misdirected."

Given those accolades, NHS pathways must surely be made available across the NHS.

I feel that NHS Direct should be just for information about illnesses and diseases, and should not involve the triage system and access. NHS pathways not only gives a person advice on where to go with their problem but makes the arrangements, but it must be integrated with ambulance services, out-of-hours providers, NHS Direct and other organisations.

Sandra Gidley, who speaks for the Liberal Democrats, mentioned ambulance response times. Most people are aware of category A, which refers to top-priority cases—75 per cent. of which are supposed to be reached within eight minutes. I do not think that the other categories are sufficiently well known. Another tragedy in my area is under investigation at the moment. It appears that an out-of-hours GP did not assign sufficient urgency to a request, so the ambulance was delayed, with desperate results. Ambulance prioritisation categories need to be widely known.

Staff at accident and emergency departments have been praised a lot today, and I fully echo that because I know how hard they work. However, my main concerns are to get those who do not have an A and E department to the right place at the right time, to prevent them from being taken unnecessarily to such departments and to plug the three-digit number and NHS pathways. If those things could be achieved, tragedies such as the one that happened to the little boy in my area would be much less likely. That little boy's parents would really appreciate such a memorial; they might almost feel that some good had come out of their tragedy.

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Photo of Nadine Dorries Nadine Dorries Conservative, Mid Bedfordshire 2:54 pm, 21st January 2009

I come to this debate with a range of experience of accident and emergency units. I was working in the A and E unit of Royal Liverpool university hospital on the night of the Toxteth riots; we admitted just over 350 people that night. I therefore have experience of acute care at its most acute. I have also worked in a minor injuries unit in the same region. The unit was a new development in the area and it came about as a reconfiguration. However, it was not led by government or driven from Whitehall—it was designed locally by the local hospital trust and local people.

The minor injuries unit worked well. Everybody in the area knew what they should go to the unit for and what they should go to the accident and emergency department for. The unit dealt only with minor injuries; we sutured, X-rayed and set basic fractures. The local community knew that, because the unit had been established following local consultation, including GP-patient groups. What was designed and established was what the local community needed, so the community blended well into that provision and used it well.

The Secretary of State said that one of the prerequisites that Darzi had mentioned was that services should be "locally led", but he endorsed what the Government are doing by using the words of the national clinical director of emergency care, who did not mention consultation or interaction with local communities, patient groups or GP-patient groups. It feels as though the reconfiguration is being driven by Whitehall rather than by patients, users, doctors or nurses.

Would the same overall blanket approach work with polyclinics? That approach is being taken with them and although I do not disapprove of polyclinics in principle, I believe that local communities have local needs and that polyclinics would work in some areas but would not work at all in others.

Some of our patients in the Royal Liverpool university hospital on the night of the Toxteth riots came through our doors in shopping trolleys. I will not forget the scene of almost carnage outside the A and E doors as I left after a 12-and-a-half-hour night shift; I do not think that the working time directive would have worked very well in that instance. I do not even know from where we drafted some of the people who worked on the unit that night; we dragged members of staff from all the wards.

The one thing that I know about working on A and E is how the relationships, expertise, knowledge, and trust and respect for colleagues build up over time. Such departments are unlike any other in a hospital, perhaps because they get the blue-light jobs and the cases that they deal with are frequently matters of life and death, or perhaps the explanation is the high level of expertise deployed and the high level of training needed by both the nurses and doctors. The departments that interact with A and E—physiotherapy, radiography—all link in as well. There is a high level of skill in A and E departments, and it builds up not only through training but through the other staff.

I am concerned that we are losing those skills because of some of the targets, because of the reconfiguration that is taking place and because of the loss of morale and disenchantment among some staff. Last week, I spoke to two nurses who are now working in GP practice having worked at Bedford hospital and at Luton and Dunstable hospital. Both had left A and E as a result of centrally imposed targets. One of them said that she decided that the time to leave was when she put the phone down after she had been told that she absolutely must admit a patient from an ambulance that had been parked outside with a patient inside for some time in order not to contravene the target once the patient came in through the doors. If she had acceded to that call and admitted the patient, she would have seriously comprised the quality of care that was being provided in the unit, given the short number of staff she had on duty on that day. She was left with the option of transferring staff quickly out of the A and E department into inappropriate wards that also did not have the correct number of staff with the correct training, skills or ability to look after the patients who were in A and E at that moment.

The nurse was dealing with a road traffic accident, or RTA. In my day, almost everyone involved in an RTA ended up in hospital, but because of the safety requirements for most cars today only the very serious cases end up there. If somebody does require serious treatment they are usually very ill, and if there is not a trauma unit nearby they will end up in A and E. The nurse had some very seriously injured patients in her A and E department as the result of an RTA, and while she was trying to care for her patients she was being harassed to take in other patients to meet a target. That was the day when she decided to walk, and we lost an absolutely superb, well trained nurse manager from an A and E department who had worked there for 12 years and built up an incredible level of expertise. The nurse from Luton and Dunstable hospital had done exactly the same thing. The figures show that we are losing nurses from A and E departments all over the country because of the targets that are being imposed.

No mention has been made of the patients who have to loiter outside A and E departments in ambulances or how that impacts on ambulance crews. Sandra Gidley talked about the waiting times from when the call is received to the ambulance getting to the patient, which are longer in rural areas. It is increasingly difficult to get ambulances to respond in the time that we need when they are still parked outside A and E doors because their patients cannot get through the doors because they might contravene a target that has been imposed on A and E staff. If the Government were going to start configuring A and E services, they should have looked at some of the existing fundamental problems before they started to look at how they farm out the entire service.

Minor injuries units, like polyclinics, can work well where there is a community need, but that need will not always be there. In fact, polyclinics can absorb much of what minor injuries units do. A minor injuries unit would probably be needed in an urban area with a high population density that is located a fair way away from a major hospital. Those are probably also the areas that would be better suited to a polyclinic, so it could be possible to deal with minor injuries at a polyclinic and combine the two things.

The Royal College of Nursing agrees that the four-hour target is compromising the patient care being delivered in hospitals. That does not only apply to situations such as the major RTA that I mentioned. For example, instead of a patient who is in need of surgery, there may be a stroke patient who needs monitoring. Let me cite an example from my constituency. A patient who was 14 days post-delivery presented at her GP surgery with a hot calf, pains in the leg and breathlessness. She obviously had a pulmonary embolism and was sent to the A and E department. She was farmed out from that A and E department to the paediatric ward, but the right dosage of Heparin, which she needed to be given fairly quickly, was not available. The nurse therefore had to go back to the A and E department to get the correct dosage of Heparin and take it back to the patient. As a PE is a fairly serious condition, it would have been far better if she had stayed in the A and E department, been treated and monitored, and then taken to an appropriate ward when a bed was available so that she could be nursed properly, but unfortunately that did not happen.

Like Joan Ryan, who mentioned her granddaughter, I have experience of using A and E units not as a patient. Sadly, my own brother died in a unit where I was working at the age of 26, following a road traffic accident. He stood a chance when he arrived though our doors because he had been treated by a paramedic at the scene of the accident. Two dual-man ambulance teams arrived at the scene of his accident, and he was still alive when he arrived with us. One of the Government's proposals is to split the dual-man teams and revert to solo response teams. I am concerned about that. When a solo response team attends a serious accident, several things need to be done. Following a road traffic accident or a serious trauma, a patient will go into peripheral shutdown and will need to have a line put up pretty quickly. That is very difficult to do if there is not the correct level of assistance. It is hard to introduce a line in order to put in the intravenous drugs—the adrenaline and other things that will be needed to keep that patient stable until they get to an A and E department. One person cannot maintain a clear airway, administer drugs, deal with peripheral shutdown and insert a line if they are on their own or do not have the right level of expertise with them. It is not just about the clinical needs at the scene of the accident—they may have chaos around them, agitated and upset people, or more than one person requiring their help. If this move towards solo response teams becomes popular, patient care at the site of an accident will be compromised. I do not think for a moment that my brother would have got through the doors of the A and E if he had been treated by a solo response team.

The Minister has claimed that the solo response team does not present a risk to patients and frees up resources for other calls. He said:

"Fast-response vehicles can often get to the scene faster than traditional ambulances."—[ Hansard, 17 December 2007; Vol. 469, c. 1195W.]

I am sure that they can, but I do not see why there cannot still be a dual-man team in the solo response vehicles. Why cannot there be two paramedics? Is the Minister referring to the fact that ambulances are larger or that they go more slowly? I am not sure why he is saying that solo response vehicles will get to the scene more quickly. [ Interruption. ] The Minister is indicating to me that a motorbike would be used. That is fine, but how would one man and a motorbike deal with peripheral shutdown? How would he maintain a clear airway at the same time? How would he administer drugs? How would he deal with the agitated and upset people at the scene? How would he deal with other people who may be injured at the scene? How could one person do all that? It is difficult enough for a dual-man team who are very pressurised and under a great deal of stress when they attend these scenes. How does one man on a motorbike deal with that scenario? I hope that the Minister will elaborate on that, because it causes me more concern than any of the other proposals. I understand the need to free up resources, and perhaps he wants to have more ambulances so that we can speed up response times, but I ask him to look at the four-hour target first.

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Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

There is a related issue. In a road traffic accident, the ambulance service will obviously aim to dispatch an ambulance that is capable of transporting a patient, and there would therefore be two staff present. However, the question that often arises is whether that team includes a paramedic who is capable of intubating a patient at the scene of the accident. It was interesting to note that the national confidential inquiry found that 41 per cent. of patients who were treated by a helicopter-based system were intubated at the scene before being taken to hospital, while the figure for patients treated by road ambulance teams was only 7 per cent.

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Photo of Nadine Dorries Nadine Dorries Conservative, Mid Bedfordshire

That is a really interesting statistic. Intubation has a huge impact on a patient's ability to get to an A and E or trauma unit to receive the second level of care that they need. My hon. Friend makes a fascinating point. I would say that it would be almost impossible for that figure not to be even lower than 7 per cent. under the solo response proposal. I am sorry to do this to the Minister, but I must quote his words again, because it is quite frightening that he believes that a solo response system

"does not present a risk to patients".

I believe that those teams would present a considerable risk to patients, not because of anything to do with the commitment or ability of the one paramedic on the motorbike, but simply because that one paramedic does not have four arms. He does not have the ability to deal with whatever he might find at the scene of an accident on his own. It is a frightening scenario—

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Photo of Sylvia Heal Sylvia Heal Deputy Speaker

Order. I am afraid that the hon. Lady's time is up. I apologise—there was a mistake on the clock. It looked as though she had an extra two minutes, but in fact it was only one. I do apologise.

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Photo of Edward Timpson Edward Timpson Conservative, Crewe and Nantwich 3:11 pm, 21st January 2009

May I add my praise and admiration for the dedication, professionalism and sheer hard graft of all those in the emergency services, who do so much to help so many of us? In particular, I should like to praise my local hospital, Leighton hospital, and to thank my hon. Friend Mr. Lansley for mentioning the great work that it does. Its staff often work in difficult, traumatic and treacherous circumstances, and they deserve the highest praise that we can give them.

The Secretary of State mentioned the capacity of our A and E units to cope with the demand, particularly over the Christmas and new year period. He talked about shutdowns, during the 1980s and 1990s, in A and E departments that could not cope with the demand, and said that that was a thing of the past. Sadly, however, Leighton hospital had to close for six hours over Christmas because it could not cope with the demand coming through its doors, despite the long hours and hard work put in by the staff. We have to recognise the fact that that problem is still out there, and work even harder to ensure that we have the capacity to cope with such demand at any time of the year, including the Christmas period.

In this important debate, I particularly want to highlight the often unrecognised, unsung work of our community first responders. We must remember that they are volunteers who give up their own time and money to care for people in our local communities, who rely on them not only to respond to tragic accidents but to save lives. They perform a vital, life-saving service in Crewe and Nantwich, and that is recognised by, and embedded in, the local community. I have had the privilege of meeting a number of community first responders, not only in my own constituency but across Cheshire. It is clear that they are extremely highly regarded, not only by local residents but by the local councils, by the control centre staff with whom they deal directly, and by the paramedics on the ground, who appreciate the great work that they do. Unless we have full paramedic coverage and a blanket of defibrillators across an entire area, community first responders will have a role to play in ensuring that they are available to support their local community wherever their care and professional ability are needed.

Community first responders are a key component in relation to the response times to emergency calls. Unfortunately, the response times in Cheshire have historically been unsatisfactory. Indeed, last year, the North West Ambulance Service fell almost 20 per cent. below its target for reaching calls to life-threatening cases within eight minutes. As many Members will know, the sooner a response can be made, the better chance there is of survival for that patient. Every second is critical when a life is under threat.

Other Members have highlighted the fact that local ambulance trusts are able to hide behind their regional statistics on response times. Those statistics often mask great deficiencies in the local response times throughout the area. We have already heard about one area of the country in which the local ambulance trust has failed to respond to all category A calls with the target eight-minute period. Indeed, that also applies in the Audlem area in my own constituency, where 100 per cent. of the category A calls were not reached within eight minutes.

That serves only to re-emphasise the importance of the role that the community first responders play in our local communities. I am delighted that, after the three meetings that I have had with the chief executive of the North West Ambulance Service, he and the local primary care trust—and my hon. Friend Mr. O'Brien, who sits on our Front-Bench shadow team—have managed to put together a working group to look at local response times and to encourage the ambulance service and the community first responders to work together, to ensure that whenever there are professional, qualified community first responders available, they are called on, so that everyone in the local community has the best chance of getting a response as soon as possible.

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P

Edward has researched this issue, fully understood the problem, and elegantly exressed it to the House. A wonderful speech, covering all of the important points in a concise manner, and offering overwhelming arguement to support the Community First Responders. There can be no greater joy than to save another person's life. There can be no greater dismay than to see a person die for want of a better system. Let's hope the system is improved soon.

Submitted by Paul McHugh

Photo of Stephen O'Brien Stephen O'Brien Shadow Minister (Health)

My hon. Friend is to be congratulated on the tremendous vigour with which he has fought the campaign to get some sense into the restoration of a good community first responders service, not only in his own constituency, since fighting the by-election there, but in the neighbouring area, which includes my constituency, and the more rural areas of Audlem and Buerton. I hope that he agrees that there would be no need for community first responders if the performance of the North West Ambulance Service were at least up to target, either in the more urban environments in his own constituency, or in the remoter rural parts of mine. The service's targets have been missed by a large margin, and, with the restraint put on the community first responders, we now face a major challenge in getting our constituents to Leighton hospital so that their needs can be met. I am grateful to my hon. Friend for his efforts, but I wonder whether he agrees that the community first responders are effectively filling a major gap that has arisen due to the inadequacy of the North West Ambulance Service? The service has repeatedly been challenged on this matter, and we have reached the point at which we demand answers.

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Photo of Edward Timpson Edward Timpson Conservative, Crewe and Nantwich

I am grateful to my hon. Friend, who has got to the nub of the issue. One of the community first responders in Nantwich has told me directly, "I wish I didn't even have to be here." He said that he had to fill in the gaps, as my hon. Friend says, to ensure that there was a proper service that met the needs of the local people of Nantwich. Although he enjoys his job and gets great satisfaction out of it, he would prefer not to have to do it. If there were a 24-hour paramedic service on the doorstep of everyone who lives locally, he would certainly not have to.

A process is taking place that the North West Ambulance Service calls a "standardising" of the service. It is essentially downgrading the role that community first responders play in the local community. It is taking away the life-saving drugs that they administer at the scene of an accident or in a case of trauma, and reducing their responses to certain calls such as those involving children. Perhaps most concerning of all, it is taking away their ability to use a blue light as part of their response. The original intention behind community first responders was, to quote a report by the Healthcare Commission on the Staffordshire ambulance service,

"to provide a prompt emergency services for communities that ambulances could not reach so quickly, and to improve the outcomes for patients where the speed of the first intervention can be critical, especially those with chest pain or having a cardiac arrest."

The removal of the blue light has disabled community first responders from ensuring that they can get to the scenes of category A and other calls as soon as possible. As a result, the number of calls to community first responders in the Nantwich area has been reduced from about 80 a month to just one or two a week.

Sadly, the removal of those responsibilities of community first responders last May came at a time when a young father in my constituency needed their help. In a tragic incident, the ambulance was unable to reach him within the specified eight-minute period. The community first responder was not called, because of the downgrading of the service, and the young father died. The justification for the standardising of the North West Ambulance Service was the Healthcare Commission report that I have just cited, but of course the role of community first responders is different for each trust. In Nantwich, the responder is someone who not only has many years' experience in the role but is qualified at the highest standard to drive with a blue light. It seems bizarre in many respects to take away the opportunity for him to respond as quickly as possible, given that he has both the training and professionalism to do so. He has done so for four years with no incident. Restricting the capabilities of the community first responders potentially puts lives at risk.

The Secretary of State said earlier that he wanted change for the benefit of patients. We certainly want such change, but we have not seen evidence that the changes to the responsibilities of the community first responders are an example of that. The depth of feeling about their role is palpable in my constituency, as I am sure it is in constituencies across the country. The situation has led not only to a petition of more than 10,000 local names being signed and delivered to Downing street but to the first march through the streets of Nantwich for a considerable time. Having spoken to some more expert local historians than I am, I understand that it is the first since the civil war. That is how strong the local feeling is. The community first responders are held in very high regard and provide a valuable service. The sooner a highly qualified community first responder can be on the scene, the greater the chance of a successful outcome.

We have been told that the North West Ambulance Service wants to expand the community first responder service, and indeed it has started to make moves in that direction. However, new CFRs are becoming qualified on the basis of just 18 hours of training, without responding to the category A, B and C calls that, as Dr. Taylor pointed out, need to be recognised as part of their service. That seems an unfortunate way in which to treat people who volunteer their services and have the capacity to ensure that the response times are met. They also offer two other benefits.

First, community first responders are great value for money—they do not ask for anything for their actions; indeed, they plough in their own money to perform the task. Local financing—often given by town councils and other charities—covers their role. They therefore provide a direct benefit to the NHS and the local community. Secondly, they are not only locally accountable but they have immense local knowledge. An ambulance that comes from many miles away may have directions about how to reach the patient, but the driver may not know the patient, and may not know the road intimately or be able to get there as fast as a community first responder. Local knowledge is therefore vital in providing the service.

It is time for ambulance trusts throughout the country, especially in my area, as well as the Government, to listen to the voice of the public about a service that is vital but currently undervalued. The community first responders have shown that they are willing not only to serve but to give to the best of their ability. It is only right that they are allowed to do that.

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P

Edward has researched this issue, fully understood the problem, and elegantly exressed it to the House. A wonderful speech, covering all of the important points in a concise manner, and offering overwhelming arguement to support the Community First Responders. There can be no greater joy than to save another person's life. There can be no greater dismay than to see a person die for want of a better system. Let's hope the system is improved soon.

Submitted by Paul McHugh

Photo of Sylvia Heal Sylvia Heal Deputy Speaker

I now have to announce the result of a Division deferred from a previous day. On the motion relating to Northern Ireland, the Ayes were 276 and the Noes were 184, so the question was agreed to.

[The Division list is published at the end of today's debates.]

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Photo of Mike Penning Mike Penning Shadow Minister (Health) 3:26 pm, 21st January 2009

It is a pleasure to respond to the debate on behalf of Her Majesty's Opposition on such an important subject, which affects all our constituents and the whole country.

I pay tribute to all staff in the NHS, whether in the emergency or primary care sectors. They do a wonderful job and we should praise them at every opportunity. I also take the opportunity, following my recent visit with other parliamentarians to Afghanistan, to praise NHS staff serving in the Territorial Army, especially in the emergency centres and triage centres in places such as Camp Bastion, which could not survive without the NHS contribution to our armed services. Their work there is simply fantastic.

We are in a sad predicament. At one stage, when I looked at the Government Benches, I thought I was in an Adjournment debate. Only one Labour Back Bencher made a speech on the NHS. Remember 1997 and "24 hours to save the NHS"? Yet the Government Benches could not be filled for such an important debate. Only one Labour Back Bencher, who is desperate to save her seat, contributed. If she returns, I shall consider her speech shortly.

Let me consider the Secretary of State's opening remarks. I want especially to deal with urgent care. It worried me that the right hon. Gentleman referred to another review, which may happen sometime in future, into urgent care, especially a second emergency number. When looking at my notes, I found it interesting to remember that the Government promised us a framework for urgent care three years ago, in 2006. Six months later, Lord Warner promised a strategy by the end of the year. In the first half of 2007, Ms Winterton promised that we would have an answer about the secondary number. Again in 2007, Lord Darzi mentioned it in his reports. Now, in early 2009, the Secretary of State mentions it again. We do not need it to be mentioned; we need action.

This morning, Ofcom stated in its parliamentary briefing that it would conduct an immediate review—I hope that the Secretary of State is aware of today's announcement—and that it will look into the numbers that are available as well as 999. I will deal later with some of the comments about whether we need a second number or whether everything can be done through using 999.

Ofcom has specifically said that it would be inappropriate to use 888. Most people understand that, especially those who live in London. Anyone in the area covered by the 7 code who had to dial 8 could end up dialling 888 inappropriately. However, Ofcom has suggested that it would be possible to use not only the 116 116 numbers, with the permission of our European friends, but triple numbers from 102 to 119, including 117. Myriad numbers are available should the Government wish to proceed. Ofcom is on board. We have been calling for the change for two and a half years. It is imperative that the public have a simple way of accessing urgent care, not myriad different services all the way through.

We have heard many contributions today, mostly from the Benches behind me, and it is important that we consider some of them. The Liberal Democrat spokesman, Sandra Gidley, talked about 116 numbers, but she was slightly confused when she said that she did not want the public to go through an operator system. That is not what is proposed. Most of the ambulance trusts operate a system similar to what is proposed already. My concern is duplication. We do not have unlimited cash in the NHS. We cannot have the public confused with different numbers; nor can we have the cost of different services by different agencies.

There was also some confusion when the hon. Lady responded to the interventions that my hon. Friend Mr. Burns made on her. The ambulance service is a complex system and we need to try to understand how it operates. I ask the hon. Lady to go to one of the ambulance trusts and to sit there while staff are doing a triage call, because it is fascinating. The minute a call comes in, staff are dispatched, based on the location of the call. They would much rather turn back an ambulance or downgrade a call than worry that they were not getting people there.

There is a concern about the eight-minute call, which means that staff need to get someone there within eight minutes 75 per cent. of the time. We understand that. What cannot happen, but what is happening—this has followed the amalgamation of the ambulance trusts, although I do not think that it was intentional—is that, because the number of responses getting there in time is grouped, if an ambulance trust has an urban and a rural part, which most do, it can have an attendance rate of almost 100 per cent. in time in the urban part, but almost zero in the rural part. I am sure that that is the point that the hon. Lady was trying to make.

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Photo of Mike Penning Mike Penning Shadow Minister (Health)

No, I have to stick to my time; that is the problem with this sort of debate. The point is that the issue of the 116 number could be addressed almost immediately.

I am really disappointed that Joan Ryan is not in her place. She made a contribution of nearly 15 minutes, in which her position on the future of Chase Farm hospital flip-flopped. In the consultation on Chase Farm she opted for option 1, which is to downgrade the Chase Farm A and E facilities. That was her position then. Her position today is that she is fighting to keep all the facilities at Chase Farm. The right hon. Lady cannot have her cake and eat it. Either she is for her Government, who are willing to close the A and E department at Chase Farm, or she is not. It will be this Government who will close the A and E departments at Chase Farm hospital, at Welwyn Hatfield hospital and, yes, at Hemel Hempstead hospital. That is something that I go on and on about, and I am very proud to do so. The reason why I go on about it so hard—it is also why my hon. Friend Mr. Burrowes is in his place, unlike the right hon. Member for Enfield, North—is that the community does not want to lose the life-saving facilities that they have now.

The Secretary of State was trying desperately to say that we should take no notice of the experts who say that an urgent care centre—or whatever title we want to use—is not a replacement for an A and E department. The right hon. Lady went on about the myths propagated in her constituency; and interestingly enough, she came up with a myth herself. She should have looked at the report that the College of Emergency Medicine published just before Christmas. The College of Emergency Medicine issued a list of myths, and the right hon. Lady managed to hit the first one. "Myth 1," the College of Emergency Medicine says, is that

"60 per cent. of patients attending an A&E department could be seen, to the same clinical standards, at less cost, in other settings"—

[ Interruption. ]

I understand from my hon. Friend Mr. Lansley that the Secretary of State said the same thing. In fact, the College of Emergency Medicine—I am sure that the Secretary of State would agree that it is an expert—says:

"Between 5 and 10 per cent. of patients attending an Emergency Department...should be treated in primary care".

We accept that. It continues:

"Another 20 per cent. of patients could be treated in primary care" settings, but that is it. So the absolute maximum percentage of patients attending an A and E who could—not should—be treated is 30 per cent. The myth propagated by the Secretary of State and by the right hon. Lady is that it is 60 per cent. That, frankly, is wrong.

My hon. Friend the Member for West Chelmsford provided a wealth of experience—not only from his time as a shadow Minister, but as a member of the Health Select Committee before my time on it—and showed us just what could be done if we engage with the hospital in the local community. The information that he put forward was absolutely vital. I completely agree with him that many of the problems of emergency departments are to do with alcohol and alcohol abuse, and I agree with him about the assaults and abuse that NHS hospital staff have to take. The Government could do something about that tomorrow—and the Secretary of State should do something about it tomorrow. Why are only one in 1,000 assaults on our brave and professional emergency staff prosecuted? Perhaps the Secretary of State or his ministerial colleague would like to intervene to explain why our staff are assaulted on a daily basis, yet prosecutions do not take place. The right hon. Gentleman said at the start of his speech that he was dedicated to the staff and he praised them, so why are we not protecting them? My hon. Friend raised a very important issue.

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Photo of Mike Penning Mike Penning Shadow Minister (Health)

I said no to the Government side, so I am saying no to this side— [Interruption.] Believe me, I meant that I am not giving way to anyone on any side.

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Photo of Bob Spink Bob Spink Independent, Castle Point

Conservative Front Benchers intervened five times, so the hon. Gentleman should give way

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Photo of Alan Haselhurst Alan Haselhurst Deputy Speaker and Chairman of Ways and Means

Order. We do not want sedentary comments from any part of the House, as they do not help the debate.

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Photo of Mike Penning Mike Penning Shadow Minister (Health)

Thank you, Mr. Deputy Speaker.

My hon. Friend the Member for West Chelmsford and others raised the issue of getting ambulances to A and E departments and then getting the patients from the ambulance into them. That is a crucial issue. Many clinicians at hospitals have said that they sometimes end up looking at the clock rather than treating patients because they are so worried about the four-hour limit. We have proposed to abolish it and we look forward to seeing it go.

Dr. Taylor has campaigned on these issues for many years and has a vast knowledge to draw on. He spoke about duplication in respect of NHS Direct and other services, which I alluded to earlier. I am not sure whether the hon. Gentleman is aware of it, but his own ambulance trust, which I understand is the Great Western

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Photo of Mike Penning Mike Penning Shadow Minister (Health)

I apologise, I was informed that it was the Great Western trust.

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Photo of Mike Penning Mike Penning Shadow Minister (Health)

I stand corrected. This is fantastic: the Great Western trust is being looked after by the West Midlands trust, because the Great Western could not look after the situation itself; as its results were so poor, Anthony Marsh, the chief executive of the West Midlands trust, has gone across to help it. Let us hope that the situation improves.

The hon. Member for Wyre Forest also spoke about a very sad case of a young boy who died in his constituency. I am sure that all our thoughts and prayers are with the family. It is so difficult when that sort of things happens in our constituencies, as it does every now and again. People needed the help of the NHS; sadly, they were let down. We look forward to seeing the results of the inquiry.

My hon. Friend Mrs. Dorries never ceases to amaze me with her depth of knowledge. She worked in this sector and took a huge interest in health issues while she was there. Many of us may have worked in different areas of different industries over the years, but we have not absorbed to the same extent as her an understanding of where the problems lie. My thoughts were with her as she talked so powerfully about the loss in her family.

I bring my own experience to the subject of what used to be called road traffic accidents—we have changed the language over the years, but I will continue to call them RTAs. When I first joined the fire service, I came in with a paramedic qualification from the armed forces. I was asked to take a first aid course. That is where we were. I sat so often at road traffic accidents and saw how the medics—there were no paramedics in those days—did their very best to keep going the vital signs of people whom we were trying to extricate from vehicles. Very often, people died. I had the most appalling experience with a young lady who had a stoved-in chest and was drowning internally; no one had the ability to drain her or keep her airways open. That, thank goodness, has changed.

Although I understand my hon. Friend's concerns about single responders, I have been present at RTAs that it has been physically impossible for an ambulance to reach—let alone an air ambulance, if one was available. Bikes do get through, however. She is right to say that they are not a replacement for a two-crewed ambulance, and it is vital that ambulances are dispatched at exactly the same time. I also understand her point about all the different techniques such crews need to have, and that it is better to have six hands than four or even two. Two is better than none, however; I have been at RTAs where there have been none, and it is better to have someone there. I agree that we must make sure that we do have not only single responders, but I do not think that is the situation; I have not met an ambulance trust chief executive who has told me that they have only single responders to RTAs, and I have asked every time. If that were ever brought in, it would be fundamentally wrong, and I am sure the Secretary of State would object to that, too.

However, there is a crisis in the ambulance service involving the difference between paramedics and technicians and what has been described as the wonderful new skilled roadside role of the emergency care assistant. I had in the past understood that in no situation would an ambulance go out without a paramedic or technician on board, but it is now my understanding that, at present, ambulances with under-qualified staff on board are responding to emergencies and they are invariably called emergency care assistants. That is very worrying. Over the years, we have built up the skills of paramedics. They have increased, not least because of the extra skills they pick up on operations with the military and then take back into the domestic sector. We cannot go the other way, and allow decreased skills. At present, we have paramedics on the one hand and emergency care assistants on the other hand, and something is falling through the middle: the skill base that we would all want.

Let me say a few words about queues outside hospitals. Ambulances queue up and hospitals will not take patients in because they are worried about the four-hour limit. This is no criticism of the West Midlands trust, but let me explain a situation I learned of while visiting Birmingham recently. Seventeen of the trust's ambulances were queued up outside a hospital, and the only way that they could be freed up was by putting one of the senior ambulance officers into the porch area of the accident and emergency department so that the ambulance crews handed over patients to her but not to the hospital. If that is what happens in a modern hospital service in the 21st century, something is seriously going wrong. I understand that happens around the country. It is one of the ways that ambulance trusts manage to free up their vehicles and get them back out on the road again; they have to avoid getting their patients into the hospital accident and emergency department because there is concern about the four-hour target.

My new colleague, my hon. Friend Mr. Timpson, raised an important point about how communities feel about responders. Although they are unpaid, I have to emphasise to him that they all need to learn their skills. They need to come out of their basic training; 18 weeks is a short period but it is long enough to get their basic skills together. The key is that skill base as we take them forward. If we just left them with 18 weeks of training, and they went back in the community and never had any further training, that would not be useful. In terms of my hon. Friend's comments, what particularly worried me is that the critical care which responders give is key, so excluding them from category A—in other words, saving lives at critical points—is the opposite of what we should be doing. In many respects, their job is to save lives, not just to patch up a fracture or tend to a sprained ankle. It is crucial that we use them with such necessary skills, rather than pushing them off to less important roles. I will take that issue up in my shadow role.

When making notes for winding up this debate, I knew that I particularly wanted to talk about the ambulance issue because I knew that my hon. Friend the Member for South Cambridgeshire was going to talk in his opening remarks about the accident and emergency issue. I did not want to talk only about emergency care assistants or the emergency response times. I do not think that the Government intended to happen what is happening when they moved to regional ambulance trusts, but it is happening; if the ambulance trusts were smaller, it would be more difficult for the figures to become skewed between rural and urban.

I covered the way in which the performance targets work—that is a major issue and I hope that the Minister will examine it. The crucial thing when examining the performance of a trust is that we examine the outcomes. He is disagreeing with most things that I am saying, but if he thinks that the accident and emergency facility at Chase Farm should be closed, as is proposed, and that the accident and emergency closures that affect the Welwyn Hatfield area should proceed, or if he wants to continue with the mad closure programmes for the Hemel Hempstead general hospital, he should call an election—he should go to his boss and say, "Let the people decide." The Secretary of State says that he wants local democracy, so let us have an election and let the people decide.

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Photo of Ben Bradshaw Ben Bradshaw Minister of State (Regional Affairs) (South West), The Minister of State, Department of Health 3:45 pm, 21st January 2009

I assure Mike Penning that I was shaking my head not because I disagreed with all of what he said—I think that there is a great deal of consensus on these issues—but because he took 20 minutes to say it. The debate has generally been good and positive, and we have heard many interesting and constructive contributions from across the House. We could have had an even broader debate, given that the title of the debate covers a range of issues, including not only the ones that we have discussed, but walk-in centres, general practitioners, out-of-hours services and NHS Direct. Urgent and emergency care is a broad canvas indeed.

I shall concentrate on the specific points that have been made, but if I do not have time to respond to all of them, I shall endeavour to write to hon. Members.

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Photo of Ben Bradshaw Ben Bradshaw Minister of State (Regional Affairs) (South West), The Minister of State, Department of Health

I shall give way to the hon. Gentleman, particularly as his former colleague, the hon. Member for Hemel Hempstead, would not.

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Photo of Bob Spink Bob Spink Independent, Castle Point

That is very kind of the Minister. On specialist trauma units, does he agree that getting people with strokes and other such conditions straight to the right place, rather than to any old accident and emergency facility—only for them to have to be transferred later—is crucial in preventing deaths and disability? And does he therefore accept that the Tory motion is, at best, very poorly drafted, because choice is not the relevant factor for trauma patients, but speed and specialist centre provision are?

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Photo of Ben Bradshaw Ben Bradshaw Minister of State (Regional Affairs) (South West), The Minister of State, Department of Health

Absolutely. The hon. Gentleman has pointed to the inherent contradiction in the Conservatives' policy: they say that they recognise the need for reorganisation, including the creation of trauma centres—the need for which he has described—yet they oppose every single reorganisation when one is actually proposed.

I need to correct the figures, or the impression, given by Mr. Lansley about the increase in accident and emergency attendances. A small increase in the number of such attendances took place between 1997 and 2003, but between 2002-03 and 2007 the figures for the average annual increase in accident and emergency attendances were as follows: the figure for major accident and emergency departments was 2.2 per cent.; that for single specialty accident and emergency was 4.9 per cent.; that for other types of accident and emergency department, including minor injury units, was 4.6 per cent., and that for walk-in centres was 15.7 per cent. Hon. Members can see that the biggest single proportion of the increase in accident and emergency attendances arose because of walk-in centres, which did not even exist under the previous Government, and that the smallest increase was for major accident and emergency departments. [Interruption.] The figure is not going up; the hon. Gentleman is wrong about that, too. The 2007-08 figures for major accident and emergency departments—the latest ones—show that there was a reduction of 1.5 per cent. compared with the previous year.

On the general issue of accident and emergency provision, a number of hon. Members have fairly recognised that the latest independent health watchdog report by the Healthcare Commission not only reports an improving picture—88 per cent. of the public rate their experience of accident and emergency as excellent, very good or good, which is an increase from 85 per cent. in 2003-04—but makes a number of criticisms, including some associated with pain relief and discharge, which the Government take very seriously and expect the NHS to address.

The hon. Member for South Cambridgeshire gave the reply that I was going to give in response to Mr. Burns on the gap between the findings of the Healthcare Commission's survey and the official figures. That occurs because some people may, for clinical reasons, need to be to moved into an assessment unit or a side ward if the consultant who has seen them is not in a position at that stage to make a decision on their care. Such people may still feel as if they are in accident and emergency, whereas in fact they are not. That four-hour target, which the Conservative party would scrap, has been incredibly important in driving up performance. I do not know any serious manager in the health service who thinks that it would be a good idea to abandon it. That would be a recipe for returning to the terrible days of patients having to wait hours, and even days, on trolleys, and the closure of accident and emergency departments.

It is important to put on the record what the College of Emergency Medicine report said about emergency medicine. It has been widely, but selectively, quoted by the Opposition, including in an early-day motion, but they omitted to mention that the report states on page 8:

"There is no single solution to the reorganisation of emergency care. In urban areas where" emergency departments

"are close together (less than ten km apart) there may be advantages to amalgamating some services."

It goes on to argue that that could result in a "more coherent" service for local residents.

The college's report states that, throughout the country, many patients who attend A and E but do not need the full services of an acute hospital could be dealt with in an urgent care centre on a hospital site or in a community setting. The recent independent Healthcare Commission report on urgent and emergency care found that, in a typical urgent care centre, care starts within an hour for 93 per cent. of patients.

There is evidence of highly effective urgent care centres that are properly integrated, and have good collaborative working relationships with A and E colleagues. The key issue is that services should be integrated and staffed by people with the right skills and competencies to deal with the population using the service. Whether an urgent care centre is appropriate in a particular area, and how services are best structured, will depend on local circumstances. The Opposition motion suggests that to achieve that may mean concentrating expertise in a smaller number of centres of excellence that bring together specialists in different subjects to work together as a single team.

Many people who walk through the doors of accident and emergency departments do not need such a high level of care, and for them the most effective treatment will come from a nurse or GP. We can trade figures, and other reports have been quoted, but I am advised that the most conservative estimate is that 50 per cent. of those who present in accident and emergency departments in fact require primary care. That is a huge proportion.

Of course, when any reorganisation takes place it can be, and often is, controversial. But as my right hon. Friend the Secretary of State made clear in his opening remarks, the changes must be locally led and, clinically driven and, in contrast with what Mrs. Dorries suggested, they require full public consultation. If democratically elected local councillors disagree with recommendations made by their local primary care trusts, they can object through the overview and scrutiny committee and refer those proposals to the independent reconfiguration panel. Some hon. Members have said that the panel is just a front, but in the past six months it has comprehensively rejected two major reorganisations, one in Oxfordshire and one in Sussex. It bases its decisions on the clinical case, and it was absolutely right for my right hon. Friend to take the politics out of the matter and set up a process that is transparent, independent, and based on clinical need and what is best for the patient.

My right hon. Friend Joan Ryan has championed Chase Farm hospital with great effect during her years in the House. I am sorry that she was not in the Chamber for the contribution by the hon. Member for Hemel Hempstead, but she may like to read the Hansard record, because he grossly misrepresented the position on Chase Farm and what she has done to ensure that the proposals affecting Enfield are much better than they were at the outset.

My right hon. Friend took the trouble to highlight the fact that many of the improvements in the NHS in her constituency, including GP-led health centres and the planned new polyclinics, represent developments that the Conservative party oppose—her local Conservative party is completely silent on that subject. We have had many such debates, and the national director for emergency access referred to the proposals from the local primary care trust—not the Government—on the reduction from three to two accident and emergency departments. He said:

"Put starkly, it is evident that safe, high quality modern care cannot be provided for all specialties in all three acute hospitals in the area...Care of the standard that members of the public have a right to expect will require the centralisation of some specialties on two of the three hospital sites. Immediate care around the clock by experienced clinicians cannot be guaranteed whilst efforts are made to maintain all three sites".

My right hon. Friend will also be aware that there is an outstanding judicial review application by the local authorities concerned, but the challenge from the local authorities to the Independent Reconfiguration Panel was not successful.

Sandra Gidley raised in some depth the issue of ambulances, but she did not mention that we are achieving the best ever response times. The ambulance service is the most popular in the NHS, as it scores the highest level of patient satisfaction of any service—some 97 per cent., according to the independent Healthcare Commission. Investment in ambulance services has increased by 135 per cent. since 1997.

The hon. Lady raised the specific issue of ambulance services in rural areas, and how the new larger ambulance services are expected to perform. The Department issued directions to each ambulance trust following the reorganisation of services in 2006 to set out the requirement that each trust must be able to demonstrate that it has regard to the reasonable needs of everyone in their area, and has arrangements in place to meet the national response times. The way in which each trust does that will depend on the local geography and fleet mix, and is a matter for local decision. However, since the reorganisation, ambulance services have improved their performance and displayed the highest response ever on category A calls, with 77.1 per cent. in the latest figures.

The hon. Lady—and the hon. Members for Mid-Bedfordshire and for Hemel Hempstead—also raised the issue of delayed handover of patients at accident and emergency departments. Let me make it clear again—as my right hon. Friend the Secretary of State has done on many occasions—that it is totally unacceptable for A and E departments not to accept patients, or for ambulances to have to wait outside for whatever reason. Hon. Members will be aware that the accident and emergency clock starts when the handover occurs or 15 minutes after the ambulance arrives, whichever is earlier. So if hon. Members wish to make specific allegations about such problems occurring at a hospital, they should let us know and we will come down on that hospital like a ton of bricks.

Dr. Taylor, and others, raised the issue of the three-digit number. I am sorry to have to say that they will have to be patient for a little longer. As the hon. Gentleman acknowledged, it is a complex issue, as several different models could be implemented. As he knows, we were clear about our commitment in the next stage review, and it is important to consult on the different models with all the different organisations involved, in the public interest.

The hon. Member for South Cambridgeshire rightly raised the concern about the pressure on accident and emergency departments caused by alcohol and drugs. He will, I am sure, be aware of the cross-government strategy on alcohol and drugs, which aims to address the three problem drinker groups, and therefore take the pressure off accident and emergency departments.

The hon. Member for Mid-Bedfordshire also raised concerns about solo response teams, and I will write to her in more detail. What I can say is that if, according to the best knowledge and decision making of the trust, a traditional double-crewed ambulance is required, one should always be sent—but it is important to provide a fast response as quickly as possible, with back-up if necessary.

We do not have to cast our minds back too far—just to the mid-1990s—to remember the horror stories of people waiting for days to see a doctor, waiting in corridors on trolleys in accident and emergency departments. They were waiting with neither privacy nor dignity at a time when they were at their most vulnerable. Over the past decade, this Government have transformed people's experience of urgent and emergency care. Ambulance services and accident and emergency departments are scoring record performances with a huge expansion in alternatives to urgent care for people for whom accident and emergency treatment is not appropriate. That is an enormous tribute to NHS staff, and I commend our amendment to the House.

Question put (Standing Order No. 31(2)), That the original words stand part of the Question.

The House proceeded to a Division.

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The House having divided: Ayes 230, Noes 306.

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Division number 18 Opposition Day — [1st Allotted Day] — Emergency Care

Aye: 229 MPs

No: 305 MPs

Ayes: A-Z by last name

Tellers

Nos: A-Z by last name

Tellers

Abstained: 1 MP

Abstaineds: A-Z by last name

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Question accordingly negatived.

Question put forthwith (Standing Order No. 31(2)), That the proposed words be there added.

Question agreed to.

M ain Question, as amended, put and agreed to .

Resolved,

That this House acknowledges the excellent reputation of emergency and urgent care services in the UK; commends the expertise and dedication of NHS emergency and urgent care staff who work around the clock to provide a consistent and reliable service; notes the strain placed on accident and emergency departments across the 5 country from winter viruses, and commends NHS staff for their extra efforts to maintain services in the face of such pressures; supports the improvement of acute hospital services and development of specialist centres where appropriate; acknowledges that health professionals provide excellent emergency care to 19 million patients a year in England; recognises the unique contribution made by community first responders; notes that the four hour target maximum wait in accident and emergency is hailed by many as one of the most significant steps forward in improving services for patients; welcomes the fact that patients can also access services through NHS Direct and 90 NHS walk-in centres and will soon see the benefits of 113 new GP practices in underdoctored areas and at least one new GP-led health centre in each primary care trust open seven days a week from 8 am to 8 pm; and further notes that the removal of target maximum waits for treatment will increase waiting times for patients.'.

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Photo of Alan Haselhurst Alan Haselhurst Deputy Speaker and Chairman of Ways and Means

Order. Before we move on to the next debate, I should observe that Mr. Speaker expects Divisions to take no longer than 13 or 14 minutes. I will therefore draw his attention to the 20-minute time lapse today.

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Photo of David Winnick David Winnick Labour, Walsall North

On a point of order, Mr. Deputy Speaker. Will you confirm that it is not intended to move the freedom of information order that is on Thursday's Order Paper? If that is so—I believe that it is—many of us will welcome the fact that we will not be exempted from freedom of information legislation. That was passed by the House, it applies to others and obviously it should apply to us. The move is very welcome, and I hope that you will be able to confirm that what I have just stated is the position.

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Photo of Bob Spink Bob Spink Independent, Castle Point

Further to that point of order, Mr. Deputy Speaker. May we have an urgent business statement? There is considerable confusion about what motions on Members' allowances will be taken tomorrow and under what constraints votes will be taken—in particular, whether deferred Divisions will be allowed.

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Photo of Alan Haselhurst Alan Haselhurst Deputy Speaker and Chairman of Ways and Means

Order. The matter raised by the hon. Gentlemen is, of course, strictly for the Government and not for the Chair. However, I am aware of media reports that there has been a change in the business previously announced for tomorrow. Perhaps the Government will seek to acquaint the House formally of that change. [Interruption.] If so, I assure the House that the Chair will facilitate that.

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Photo of Harriet Harman Harriet Harman Chair, Modernisation of the House of Commons Committee, Minister of State (Government Equalities Office), The Leader of the House of Commons , Member, Labour Party National Executive Committee, Party Chair, Labour Party, Deputy Leader of the Labour Party

Further to that point of order, Mr. Deputy Speaker. Perhaps I can assist the House by saying that we will seek to bring a number of the motions tabled last Thursday, in my name as Leader of the House, to the House tomorrow for debated decision—and that there is one that we will not. Let me state which ones we will take forward. We will take forward the motion that endorses the new Green Book, which we argue has tougher rules in it. Secondly, we will bring forward the motion that provides for audit and assurance, so that we can all be sure that the rules in the new Green Book are properly applied.

Thirdly, we will come forward with a proposal that every year, irrespective of whether there has been a Freedom of Information Act request, there should be publication in 26 categories of all the money that all hon. Members have spent in that year, and on what. Fourthly, there will be a motion to establish a Committee of the House on members' allowances, instead of the Advisory Panel on Members' Allowances. That, incidentally, will not have a Government majority on it. We will go ahead and bring those motions to the House tomorrow for debate and decision. But we will not be proceeding with the statutory instrument under the Freedom of Information Act 2000.

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Photo of Alan Haselhurst Alan Haselhurst Deputy Speaker and Chairman of Ways and Means

Order. I cannot cavil about the fact that the right hon. and learned Lady has responded so quickly to what I said, but she will understand, as will other hon. Members, that that places me in difficulty in that we have a time-limited debate for which many hon. Members have applied to speak. We cannot have a full debate on the contents of the statement made under a point of order. However, in the circumstances, because this is very much a House of Commons matter, I will allow the hon. Members for Rutland and Melton (Alan Duncan) and for Somerton and Frome (Mr. Heath) briefly to respond. I hope that everyone will understand that then we really must move on: we cannot treat this as a business statement pre-empting the other business of the House.

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Photo of Alan Duncan Alan Duncan Shadow Leader of the House of Commons

Further to that point of order, Mr. Deputy Speaker. I am grateful for your guidance, and of course we will leave most of these matters until tomorrow. May I seek from the Leader of the House clarification on the status of the last four years of receipts now that the attempted motion to stop their being revealed has been removed? Will they be published in full, as now appears likely?

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Photo of David Heath David Heath Shadow Leader of the House of Commons

Further to that point of order, Mr. Deputy Speaker. Obviously, many Opposition Members will greatly welcome the withdrawal of the statutory instrument on freedom of information. However, is it in order to proceed with a publication scheme that is expressly not in accordance with the judgment of the High Court?

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Photo of Harriet Harman Harriet Harman Chair, Modernisation of the House of Commons Committee, Minister of State (Government Equalities Office), The Leader of the House of Commons , Member, Labour Party National Executive Committee, Party Chair, Labour Party, Deputy Leader of the Labour Party

I will have to discuss with the Clerk of the House how the House authorities—the data holders—will proceed with the existing 180 Freedom of Information Act requests. I am not trying to stonewall on this, but I have not yet had a chance to speak to the Clerk of the House. I will do so, and we will debate this further tomorrow.

The Liberal Democrat spokesperson asked whether this obviates the need for a publication scheme for the generality of all Members of the House. The publication scheme will provide information to members of the public, without its having been requested, on all Members of the House every year. However freedom of information requests are dealt with, it is still important that as well as having tough rules and robust audit, we have a scheme to put in the public domain, without its having been asked for, information about what all Members are spending every year, and on what.

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Photo of Alan Haselhurst Alan Haselhurst Deputy Speaker and Chairman of Ways and Means

Order. The House has now heard officially about a change of business for tomorrow, and we must move on.

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