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Accident and Emergency Services

It is a pleasure to serve under your chairmanship, Ms Clark. I understand that this is your first time in the Chair, and you are to be congratulated. Obviously, years of fierce political independence have finally paid off. The subject today is accident and emergency provision. We have to accept that most TV hospital dramas are set in casualty departments, in the same way that most soap action seems to take place in pubs. That is not simply because they are eventful places, but because they are actually very varied places. Traditionally, every hospital has a casualty—an A and E—and it traditionally confronts a whole range of varied cases, from major trauma to self-referred cases of all kinds. Some people are anxious and simply need assurance, and some are anxious and genuinely need treatment. A and E departments also deal with the self-inflicted consequences of over-indulgence in legal or illegal drugs. Alcohol is, of course, regrettably an enormous source of business to A and E departments. Too often, the people who come there repeatedly do not get precisely the kind of treatment that they require and need. A and E departments also deal with simple things such as sprains, breaks and simple mishaps. They deal with mental health cases of all kinds—cases showing a greater or lesser degree of urgency. What all those cases have in common is the factor of urgency. A patient either needs treatment urgently or urgently feels—which is not quite the same thing—that they need treatment. In some cases, regrettably, people are simply too impatient to seek treatment that they could get in good time elsewhere. I have made three visits to casualty departments over the past three or four years. All of them have been different in kind. In one case, I had pins and needles in my left arm, which my wife persuaded me was an incipient heart attack. I went to casualty, was given a good grilling, and was gently diagnosed as having pins and needles in my arm. As for the second time, for reasons we will not go into, I had hit myself on the head with an iron bar. Again, I was simply checked out for a large bump and a haematoma, which had no lasting consequences—or none as far as I can tell. More critically, having had an accident in a car on the M1—I was not driving—I accompanied my daughter to an A and E department in Northamptonshire. In none of those cases did I receive any treatment, but each case was, in a sense, different. Treatment in an A and E department can be very different. It can vary from massive defibrillation to a gentle word of advice; from simply a conversation to a major life-saving intervention. The bottom line is that A and E departments are everybody's community back-stop. It is their security; knowing that there is one in their town is crucial to a lot of citizens. As what is in an A and E department varies, they are very hard to assess by any normal yardstick or benchmark. They require a whole formidable range of skills. The skills to deal with someone who has had a cardiac arrest differ markedly from those that might be required if someone wanders in in a confused or deranged state. A and E departments have tried to deal with this informally and internally by, to some extent, organising their work streams in different ways. My local A and E department in Southport used to have a colour-coding system. One would be told what colour one was, and attached to that colour was an expected waiting time. One knew where one was, in priority terms. There was—and there still may be—the expectation, and maybe the hope, that the patients, the users of the service, would appreciate that kind of prioritisation and understand what it is about. After all, nobody wants to wait for a long time for something they themselves have defined as urgent care. Unhappily, in many hospitals some of the customers—if I can use that inappropriate term—do not always feel that they ought to wait as long as they should, even when there are higher priority cases being dealt with. Recently—this is where the trouble starts—within the NHS there has been an attempt to disaggregate work streams. There are two reasons for that. One is that it is thought that A and E departments are dealing expensively and inappropriately with all sorts of cases that could be dealt with better in other settings; or that doctors are referring cases to A and E departments in circumstances where references should be made to other facilities or alternatively dealt with by the doctors themselves. Secondly, there is a raft of very good research that shows that in the case of the most severe traumas, the most critically injured and sickest patients are better dealt with at a major trauma centre that is kitted out and has all the facilities and expertise necessary to deal with the problem. We all have to recognise that there is quite a lot of empirical research about survival rates that points in that direction. The net effect of both those thrusts is that across the country there has been a downgrading of many A and E departments at many district general hospitals. Given that they are the community back-stop for many people, there is significant alarm attached to that. One notes, in Health questions and so on, that that is a common refrain. The situation is aggravated in many cases by the fact that the NHS, by and large, disowns any interest in transport arrangement. Having reconfigured services, it does not think too hard or too long about how people will get to those services. Superimposed on that is a degree of political manipulation of the proposed changes, because they are politically very sensitive. We have had an independent MP elected to this place purely on the back of the reconfiguration of such services. In many cases, there is an attempt to think the matter through, and to soften the change and manage whatever changes are deemed necessary by means of the introduction of community facilities—walk-in centres, minor injuries centres and urgent care centres. That is a fine expression: urgent care centres. I think people respond positively to that. How and whether those changes happen in individual places seems to be a matter of chance, or certainly not a matter of clear planning. Across the country, we get a haphazard, patchwork system of urgent referral, if I can call it that. That is localism, if we can call it that. The Government have a responsibility here to set a standard. The public may accept that major trauma services sometimes require, even in these days of telemedicine, to be concentrated to be most effective. What they will not accept, and should not, is a longer journey for basic urgent care. That, sadly, can be what they get. I want to emphasise that point by giving an extreme example in my constituency. In my town, as a result of a report that divided the spoils between two sites in a single hospital trust, children's A and E facilities were taken 9 or 10 miles down the road to a smaller country town, Ormskirk. Adult A and E remained in the town and is still there. We have an odd configuration, with adult A and E and children's A and E in two different places. The net effect of taking children's A and E out of a town as large, and with as many children, as Southport was one of mass outrage. There were major demonstrations, huge petitions that were handed in at Downing street, and the kind of documents that eventually wash up on a Minister's desk. People recognised that a genuine problem had been precipitated by ill-advised reconfiguration. Successive primary care trusts acknowledged the problem and endeavoured to deal with it. Southport and Formby PCT, when it still existed, endeavoured for some time to progress what it called a health village, which would have had a minor injuries unit. The PCT got £500,000 for it and was going to proceed with it, but, unfortunately, it was abolished, and the hopes of the people of Southport were, pro tem, crushed. The new, successor PCT discovered exactly the same thing as the previous PCT—that there was a huge, yawning gap in service provision, which nobody could quite explain rationally and which needed to be addressed in some way. The new PCT made progress towards establishing a minor injuries, or walk-in, centre in Southport. The PCT involved stakeholders, as the previous PCT had done, as well as parents and various groups and political representatives in the town. We should bear it in mind that that was done to address only some of the issues precipitated by the reconfiguration. It was absolutely unthinkable to people that a large seaside town would have to tell children who had had any kind of accident, such as falling over on the rugby field, hurting themselves in the street or whatever, to leave town in a taxi or in their mother's car, supposing that she had one. People thought that that was wholly irrational, given the talk these days of bringing services closer to the community. For two years, we spoke to the PCT. For two years, we had meetings. For two years, we planned the new centre. Then, a few weeks ago—to some extent, this is what precipitated my calling the debate—we suddenly found that the PCT had commissioned a report saying that the centre could not go ahead. It argued that the viability of the out-of-town, Ormskirk-based paediatric A and E required there not to be a walk-in centre in Southport. It argued that the costs were prohibitive and that what is done in many other places—such as Solihull, where two hospitals have exactly the same arrangement as Southport, but deal with the matter very differently and more sensitively—cannot be done in Southport. As is often the case when someone needs a report to make their case, the PCT amassed a set of statistics, which have been questioned. It spoke to witnesses, all of whom were hand-picked to take a relatively adverse tone and not to be enthusiastic about the project. It presented shaky arguments, and as is often the case on such issues, it confused financial viability, which is a completely distinct, although important issue, with clinical safety, which is a different and separate issue. It did not bother to consult the local council's overview and scrutiny committee. It spoke to GPs, but it did not consult the GP body. The result is that the public are absolutely baffled as to why we cannot have a sensitive and sensible set of clinical networks for children, based partly in Southport. It is not just the public, but schools that are baffled. What do they do in the middle of the day if a child falls over in the school yard and someone has to take them not to a local facility, but to a facility outside town? In the past day, I have had constructive and helpful discussions with the Secretary of State for Health, and my views, far from being outrageous, strange and madly populist, are actually quite sane and rational, and it is legitimate that the PCT should take them into account. The PCT's report set out to answer a fundamental question, although, significantly, it failed to answer it: if a mum or grandmum finds that a child whom they are caring for on that day has fallen over and hurt themselves, and they think that an urgent attempt should be made to get the medical advice that is probably required, why the heck should they have to think through getting an expensive taxi, finding a neighbour to ask for a lift or doing something else that most people in less deprived areas do not have to do? I use the word ““deprived”” quite deliberately because although Southport might not be defined as generally deprived, we are deprived of a resource that is widely available elsewhere. I hesitate to argue with clinicians, and I do not know a great deal about clinical matters, but I do know something about logic, and I am fairly confident about what I know. I am confronted here with the perverse argument that if we are to have a state-of-the-art clinical facility outside town—it is suggested that it must be there because it needs to be a specialised, full paediatric facility—that can dedicate itself to playing an important role in dealing with certain things, we cannot have run-of-the-mill care in another place to deal with the ordinary hazards of childhood life. We are told that if services are to be centralised in Ormskirk, it is necessary to have no services anywhere else. That does not follow at all, because it contradicts one of the basic premises of moving A and E services in the first place—that they should not be bogged down by, or confused with, minor injuries services and that they should be fielded closer to home. It has been suggested that if what I am saying is the case, people should have nothing in Southport and should simply go to their local GP, but that presupposes some important things. It presupposes that every GP offers the kind of service that I have outlined, which is not the case. It also presupposes that everybody has a GP. People might or might not know this, but Southport is a seaside town, and a number of children arrive every week and every weekend simply to enjoy themselves. They do not have a GP in town. If they hurt themselves on the beach, they do not expect to be told, ““I'm sorry, there's nothing in this town for you. You have to go somewhere else.”” That is an absolutely absurd scenario. Southport should provide assurance, triage and a diagnostic base for the worried mum, grandma or teacher who does not necessarily need a blue-light service, but who, in most other parts of the country, would be the sort of person to turn up in A and E. The people of Southport are no longer uninformed about the issue; they have an intelligent grasp of what is required, but they have difficulty getting their point across to the NHS quango that disposes of the resources and commissions the facilities. The general direction in the country should not be that clinical networks are designed on the assumption that children, patients and parents will travel indefinitely—at any time, to any place—but that clinicians should not. I do not need it spelled out to me that there are constraints on finance in this age of austerity; finance is always an issue. Equally, it is perfectly valid, particularly in paediatrics, to say that there are chronic staff shortages in various parts of the country. The lady who did the report that was so useful and helpful to my local PCT told me that the situation is so critical in paediatrics that any new facility is almost a threat to any existing facility. However, that presupposes that the provision and availability of staff, as well as demands for them, are the same right across the country. I would take some convincing that we cannot staff a modest facility in Southport and that we must sacrifice any basic care just to keep a unit down the road going. There is a genuine need for local commissioners to think further about this issue, and, encouraged by my discussions with the Secretary of State yesterday, I am convinced that they will. I am convinced that some of the points that I have tried to get across today have got across—albeit the hard way—to local commissioners. There are, however, two important general issues, on which other Members might wish to comment, that arise from that case and from others with which I am familiar. First, there is the general issue of standards. Where, amid all the reconfiguration that is going on across the country—we think that we understand some of the rationale behind it—is the baseline standard for urgent care that we can expect and accept in the UK? Clearly, it will vary between urban and rural populations, and with the age of populations; demographic factors will kick in. We set standards for waiting, and most of us believe that such a standard should be set, although as hon. Members will appreciate, there have been all sorts of problems with the gaming that sometimes results from that, and with the difficulties generated. We should also set a standard for access; I am afraid that we are forgetting that in all the reconfigurations across the country that have been carried out on the basis of clinical advice. Someone cannot wait for a service that is simply not there. That is one issue raised by the Southport situation, and others. The second issue, which is also absolutely pivotal, is democratic accountability. What levers does a community, which ultimately pays for the local NHS in one form or another, have when its requests and demands persistently, and in some cases unreasonably, go unheeded? I am not calling for some type of naked populism; I can understand the concern of anyone in the NHS. We all tend to do things on the basis of what the crowd may or may not call for in all circumstances, but the NHS trusts are often confronted with a tension between how they want to deliver a service and how the population wants to receive it. That is certainly the case with paediatrics in the Southport and Formby area. The Minister might advise me to the contrary, but I do not think that that tension will necessarily go away if GPs hold the purse strings; it may just appear in another form. All clinicians, I think, have a predilection, for a combination of personal, genuinely clinical and philanthropic reasons, for delivering any care in an optimal clinical environment, and we cannot afford that everywhere. To some extent, that will always conflict with access issues. I sometimes think that doctors' heaven would be a massive all-capacity ward in the middle of Birmingham, with expressways joining the city to all parts of the UK in under 20 minutes. That is the implicit model behind some of the thinking that I have heard. In the real world, however, we cannot get that, but there is another way of doing things: having well-understood clinical networks with appropriate protocols. Designed in the right way, such networks can be just as safe. In their absence, we will get continual tension between communities and the local NHS on such issues. I genuinely think that there is a democratic deficit of sorts here. If I may hark back to the subject without it being too tedious for hon. Members, who may have lost interest in the topic—I hope that they have not—a genuine tension can be almost felt in my constituency. Over the past few years, what we have had is not no expenditure but too-large Darzi clinics, which we struggle to fill; people wonder how they came about. Equally, there is something that we dearly want, and the PCT has twice let us down over it. One can stop any individual in the street in my town and hear their anger about the facilities that they would like. They are not asking for utopia; they are just asking for obvious deficiencies—in children's services, in this case—to be corrected. I simply ask: why does this have to go on?