Ambulatory Care

Part of the debate – in Westminster Hall at 11:17 am on 27th April 2016.

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Photo of Ben Gummer Ben Gummer The Parliamentary Under-Secretary of State for Health 11:17 am, 27th April 2016

I thank my hon. Friends John Howell and for Banbury (Victoria Prentis), both of whom have spoken with great expertise about the place that ambulatory care has within a developing and modernising national health service. I cannot better the description that my hon. Friend the Member for Henley gave of the purpose of ambulatory care and the place it holds in his constituency, which I will turn to at the end of my speech.

For the benefit of the House and the record, I will add some examples of what ambulatory care entails for patients around the country. There is a clinical decision unit in the Royal Free hospital that provides an alternative to admission to an emergency department for patients who may benefit from an extended observation period. The James Cook University hospital has an ambulatory emergency care unit that handles nearly a quarter of all emergency admissions and manages a whole range of medical emergencies including cardiac failure, cellulitis, diabetes and low-risk gastrointestinal bleeds.

The university hospital of Leicester has a frailty unit, which supports patients who are over 70 and need treatment for conditions such as delirium, dementia and fractures. The rapid assessment and treatment unit at Queen’s hospital in Romford has greatly reduced the time between a patient being assessed and a care plan being implemented. Those examples are in addition to the example that my hon. Friend the Member for Henley gave of Townlands in Henley.

Where ambulatory units are collocated with an emergency department, patients arriving at A&E by ambulance or as walk-ins are triaged according to clinical need and directed to the unit for treatment or tests, effectively bypassing the main emergency department. Patients identified as needing specialist treatment, tests or monitoring at the hospital, but who do not need to stay overnight, can also be referred to ambulatory units by a general practitioner. Patients with long-term conditions can be booked in for regular treatments such as dialysis.

Ambulatory care units can also focus on returning patients to their homes after treatment as quickly and safely as possible, as my hon. Friend outlined. As a result, patients are more likely to have good health outcomes because they avoid unnecessary overnight stays. He outlined beautifully the principle behind ensuring that people do not stay in bed any longer than they need to. The statistics on that developing area of academic study are stark, and he put them plainly to the House for its attention, but at their core they encompass something rather encouraging for many, although not all, patients. The best principle is to keep on going. We have all seen that with our elderly relatives: the minute one stops prematurely or unnecessarily, one precipitates a decline in condition, rather than an improvement.

Ambulatory care is an exciting and important approach to providing patient care, just as my hon. Friend outlined, and it will be central to the development of the national health service in the years to come. It has not come about by accident. It is based on good science and academic study. We in the Department are led by the Royal College of Physicians’ acute care toolkit and NHS England’s “Safer, faster, better”, which is based on the royal college’s advice.

While ambulatory care units may vary between trusts, both the royal college and NHS England have provided guidance on what a good unit looks like, so the underlying principles that all units are built on are the same. The principles fall into three main categories. First, the units must be patient-focused, meeting the needs of patients through timely treatment and discharge, and bringing together secondary and primary care services to avoid admission where beneficial. Secondly, effective clinical decision making is key, ensuring not only that patients in ambulatory units receive the high standards of care we expect from the NHS, but that the patients who would benefit from an ambulatory setting are identified early and directed to the service. Finally, ambulatory care needs to form a coherent part of the hospital-wide health system and structure to improve the patient’s journey flow through the hospital. Gaining support from other parts of the system, including clinical commissioning groups, as in my hon. Friend’s constituency, and primary care more generally is key to ensuring that the potential benefits are realised.

Ambulatory care units work well as independent units within acute trusts, but they work best when they are part of an integrated system. That is why I am pleased to see that there is an ambulatory emergency care network, which allows trusts to share best practice and to understand how to improve their services further. The Royal College of Physicians estimates that more than 30% of patients admitted for medical, as opposed to surgical, reasons could be treated in an ambulatory setting. By treating and discharging patients on the same day, emergency admissions are reduced, leaving hospital beds available for those patients who need them the most. There is therefore an advantage not only to the patient but to the system as a whole, because we are freeing up capacity for people who really do need the beds.

Increasing the numbers of patients seen in ambulatory care also has the potential to reduce waits for patients in A&E, which in turn decreases pressure on wards and increases bed availability, providing benefits to patients in other parts of the system. A whole number of benefits therefore come from ambulatory care. My hon. Friend mentioned the urgent and emergency care review and the place that ambulatory care has in that. I turn quickly to his experience of it at Townlands, where some features are particularly impressive. The first is the way in which the service has been brought together in the rapid access care unit—I imagine it is called a RACU, but I am sure the people of Henley pronounce it with a soft C. I found the integration of that with the Orders of St John Care Trust next door exciting.

It is clear that the clinical commissioning group in my hon. Friend’s constituency has been thoughtful about commissioning the care needed, involving other providers of care and using beds only when absolutely necessary. It is an ambulatory care setting without beds, but if beds are needed, it has 11 beds on a three-year contract, purchased from the trust next door, and if that number needs to increase still further, it can procure such beds through the CCG’s usual spot purchasing arrangements. For people who are admitted to an ambulatory setting, beds are available if needed for step-up care—or for step-down care for people coming from the John Radcliffe or from other acute trusts that serve my hon. Friend’s constituency.

Ambulatory care allows for a far more subtle approach to people needing care. As my hon. Friend outlined, it provides much better patient outcomes, is better for the health system as a whole and is much more flexible, ensuring that resources go precisely where they are needed. That opens out a much wider point, which he alluded to elegantly—I will say it rather more vulgarly than he did—namely the serious question of how we frame community services in the future. In parts of the country, we have a far older model of community service provision based on large bed capacity in community hospitals, which are much loved by their local communities, often funded in part by the local communities and in almost every instance founded by the local communities. We know, however, that in many cases they are not providing the best care for patients. It will often be a difficult transition to a better standard of care for patients, providing them with better outcomes and releasing resources for better outcomes for all patients across the health system.

By bringing the experience of Townlands hospital to the House’s attention, my hon. Friend has shown that we can be thoughtful and direct with constituents about the implications of change, and can explain carefully how improvements that might be challenging on the face of it, because it might seem that a benefit is being lost, can produce a whole series of additional benefits that enable better patient outcomes and a better distribution of resources within the system. He has allowed the House to understand how the benefits could be more widely spread across the NHS.

I turn finally to NHS England’s plans for ambulatory care. My hon. Friend will know about the vanguard sites in place across the country. Many of them involve the use of ambulatory care systems. There are many different kinds of ambulatory care settings involved in the vanguard sites, but the principle remains broadly the same: to try to identify those areas and experiences that replicate the positive experience that he, with the co-operation of his clinical commissioning group and primary care and acute trusts, has brought to Henley, and to ensure that that is tested on a system-wide basis. We can then roll that out across the rest of the country. We have 50 vanguard sites involved in one way or another in community care settings across the country, and I hope that that will inform a far wider transformation by the end of the “Five Year Forward View” period, which concludes at the end of the Parliament.