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Emergency Care

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 dealt with 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 appropriate 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. The hon. Member for Romsey (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 the right hon. Member for Enfield, North (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.””—[Official Report, 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 trying to indicate 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.