Emergency Healthcare (Public Services Committee Report)
(9 months, 2 weeks ago)
Grand CommitteeRead Hansard Text Read Debate Ministerial Extracts
Baroness Armstrong of Hill Top
That the Grand Committee takes note of the Report from the Public Services Committee Emergency healthcare: a national emergency (2nd Report, HL Paper 130).
Baroness Armstrong of Hill Top (Lab)
I thank the noble Baroness for being here to chair this debate; I know that this is an area in which she, too, has a strong interest. I apologise to her and to other members of the Committee, in that more people who were members of the Public Services Committee at the time of the report are not here. There is a rail strike today, which indicates that the House needs to look again at hybrid proceedings when there are events such as this at the end of the week that make it really difficult for Members from outside London to be here. If we want free speech and free expression, we should do whatever we can to enable as many people as possible to participate.
It seems a long time ago since we did this report. It is not that long, but I am now involved with others who are here in another Select Committee, which is looking at integration of primary and community services in the health service. All of that is relevant to today’s debate, but I will not go down that route today.
The Public Services Committee began this inquiry last September. It was the end of the summer, when things are supposed to be easy in the NHS, and everything was going wrong. The reports of what was happening were just horrendous, and the committee wanted to look in a more holistic way at might happen. Inevitably, NHS organisation, reorganisation and turmoil took precedence, but we did look at some of the work of services such as the fire service and police service. Both said that how they could help effectively needed to be clarified, and that they should not be expected to do mainstream health jobs. We had some fascinating discussions with fire service operatives, and some good examples were given from around the country—for example, the Hull district fire service providing a full service—but they need their terms of reference, which the Government are considering, to clarify what they can and cannot do. I hope the Government will take account of that. Of course, the police have now largely said that they will not do mental health crises emergency call-outs, which is raising all sorts of questions among community health services about what will replace that intervention.
As I say, we wanted to look at things holistically, but that ended up being quite challenging, and I know that the Government find that difficult, so I will concentrate mainly on the NHS. We looked at all the obvious things and the barriers people face when they seek to access A&E. One is ambulance response times, which I will say a little bit about later. Ambulance response times were longer than we had known before. The average in June 2023 was just under 37 minutes; this is a significant improvement on last year, but it is still twice what the standard should be. There has clearly been progress, but it is not good enough. Worryingly, this year, the figure in June was higher than in April and May. I am sure that the Government are thinking about that—they need to.
In June 2023, 108,000 people waited 12 hours or more in A&E; that is 8% of people going to A&E. That is better than last year, when it was more than 120,000, but it is substantially worse than the years leading up to that. In 2021, the number was just over 60,000; in July 2020, it was less than 10,000. I will say something more about the 12-hour wait later.
We became convinced as we did the report that patient flow was in fact the key issue. If you look at the demand side in GP services, in May, just under 18% waited for two weeks for their GP appointments. In mental health services, there is still a real problem, with too many people ending up in A&E needing constant attention, with no beds available. Users of community mental health services felt that they had not been able to see community services sufficiently in the last 12 months, and almost one third said that they had not seen mental health services often enough.
I will now turn to public health funding. We all know the problem: in too many areas of the country—including the north-east, the area I used to represent down the corridor—funding of public health services has been so significantly reduced that many local authorities feel that they are not fulfilling their potential. It has been cut by 26% in real terms since 2015-16.
There are real challenges in elective treatment. I could give many examples of people who are looking to be in hospital but, because their case is not an emergency, their treatment has been delayed or cancelled. I suspect that members of the committee have very real, live examples of that, as have I in my own family. It means that people turn up in emergency services because they cannot access other services.
We also outlined lots of supply challenges. The biggest, I suspect, are the discharge challenges. Far too many patients remain stuck in hospital longer than necessary, not getting discharged even if they are ready to be. The Government have announced a range of things, including a recovery plan for A&E generally in January this year. The NAO tells us that it is still too early to know whether that discharge plan is effective; it will be towards the end of year before we know that.
Social care is in the midst of this but, tragically, the long-awaited workforce plan—I have given the Minister a hard time before about how long we have waited for it—does not mention or deal with social care. A social care organisation, which I accept is a lobbying organisation, reported last week that there were fewer employees in social care last year than before. We should be increasing their numbers and the work they can do alongside the NHS in improving discharge and stopping people ending up in hospital.
We highlighted that the number of acute beds in hospitals has more than halved over the last 30 years. The Government now recognise that they need to increase bed numbers by 5,000, but this is still a huge challenge. We do not yet know how it will happen and, therefore, whether it will.
There are real accountability and governance challenges. There is also a lack of central vision. This is crucial. The Government do not seem to have a plan, other than to say, “We’ve now got the new ICBs and they will sort it for us”. None of the evidence we heard convinced us of that. ICBs must do their job, but they need to know what the expectations are and what they will be held to account for nationally. Our committee argued that this lack of vision meant that what a good emergency service looks like and what its major components would be was unclear.
We heard different stories about and from ICBs. The interim deputy chief executive of NHS Providers said that many people saw the solutions lying with ambulance care, but that sits outside ICBs at the moment. You need to be able to pull all the levers to have an effective outcome. We got a real feeling of risk aversion—A&E services refusing to accept patients from ambulances due to the number of patients in A&E, and care homes and schools calling for ambulances when they were not needed. There was a real mishmash of people’s expectations and how they were being responded to. There was very much a risk-aversion approach, such as 111 services escalating calls to ambulances when alternative care would have been more appropriate. Risk aversion is also an issue for NHS hospitals putting people back into the community, for obvious reasons.
So there is an opportunity to take that more systemic view through ICBs. However, this lack of clarity about the power of ICBs to make services take action means that it is still unclear who the person responsible for identifying an issue will be; also, ambulance services will work with and report to multiple ICBs, which therefore presents them with another huge challenge. The NHS gave us a fairly confused picture, but again, I do not really have time to go into that, because I want now to turn to the workforce.
There are serious shortages in emergency healthcare and ambulance care, and in other sections of the infrastructure which supports and enables good emergency access. I welcome the fact that the Government have now published the workforce plan, which addresses some of the issues we raised in our report. However, there is further still to go, and the Government need to focus on implementing the plan alongside social care.
Turing to the positives, on transparency, I would like the Minister to tell us how far the Government have got on the 12-hour wait. As he knows, we picked up that there was no real honesty with the public about the 12-hour wait, and the Government promised to rectify that and make clear exactly how long people were waiting. I wonder where that has got to now. There are important opportunities for collaboration and there is some really good practice, but how will the Government make sure that that is extended?
I thank everybody who worked on the report. The committee staff—Tom Burke, Claire Coast-Smith, Aimal Fatima Nadeem, Sam Kenny and Suzanne Mason—all made very important contributions and supported us enormously.
This is a life-threatening issue. We heard some terrible stories, and we need to know that we are going into this winter with more hope and preparedness, so that the public do not have to go through what they went through last year and we can assure them of a better service from the National Health Service and the Government.
The Lord Bishop of St Albans
My Lords, I thank the noble Baroness, Lady Armstrong of Hill Top, not only for chairing this committee and producing an excellent report but on now bringing it to your Lordships’ committee for us to debate. I declare my interest as president of the Rural Coalition and a vice-president of the LGA.
I associate myself with the noble Baroness’s concerns that a subject of such huge importance has so few people speaking on it. I understand the problems, but I encourage His Majesty’s Government, the Whips and so on to look at how we can give such topics the time they deserve.
I have long expressed my concern about healthcare in England, particularly in rural areas, so I read this report with great interest. I have seen the strain on emergency care in my own diocese of St Albans, which covers Hertfordshire and Bedfordshire. In Hertfordshire, category 1 ambulance calls—those reserved for the most life-threatening injuries—were responded to in just under 12 minutes, on average, well above the national average of seven minutes.
Rural areas have always faced unique challenges in providing care and recruiting and retaining healthcare professionals to care for a predominantly older population. Of course, people who live in rural areas accept that geographical factors mean that it will be more difficult. However, a number of issues particularly associated with rurality make the problem more complex, not least connectivity. In many areas where people rely on mobile phones and there is no coverage, delivering emergency healthcare is even more challenging. I hope the Minister appreciates the profound emergency healthcare challenges faced by rural areas such as those in my diocese.
As the report highlights, it is important for us to recognise that pressures on emergency healthcare are both a cause and effect of the strain on health services across the board. They are a cause because we know that the longer people remain on waiting lists, the more likely they are to acquire co-morbidities that compound the original underlying health issue, often making treatment more complex; and they are an effect because patients often access emergency healthcare because they feel they now have no other avenues to treatment. The squeeze on healthcare services across the board, including preventive and community healthcare, manifests itself in the kind of pressures on emergency services outlined so accurately and precisely in this report.
The Government have rightly recognised the severity of the problem in the NHS Long Term Workforce Plan, which refers to the need to increase training and retention of staff rather than relying on international temporary recruitment. Statistics from the British Medical Association show that 40% of junior doctors are actively planning to leave the NHS as soon as they can find another job, and many are planning to work abroad within the next 12 months. We see a similar story for nurses: more than 40,000 left the NHS last year. With an ever-increasing workload and stagnating salaries, there is no doubting the reason why so many professionals are leaving our health service. We hear regular reports that British junior doctors are being offered packages in places such as Australia that pay more than double what they can achieve if they stay in this country.
Given the profoundly challenging circumstances in rural areas—an ageing population and problems such as connectivity for emergency workers—it is essential that the Government’s response helps to tackle them. Will the Minister assure us that the Government’s response will be properly and fully rural-proofed as we look at how we respond to it? The Government need to increase investment in people. The report rightly notes the immense difficulty and stress faced by those in the emergency care profession, compounded by shortages across the entire health service. If we cannot encourage our healthcare professionals to stay, then it seems that, unfortunately, they will vote with their feet, as so many are doing. How do the Government plan to compete with the generous packages being offered from overseas?
Then, there is the question of how we can do more joined-up thinking. I was particularly interested to hear what the noble Baroness, Lady Armstrong, said about seeing through the whole process from start to finish and trying to work out how people move through the system, so that it can be done efficiently and effectively. Allied to that is the question of how the NHS and others are going to work with the third sector, with so many churches, community groups and medical charities being capable of offering non-urgent care support. We need to think about how we can relieve the pressure on emergency care described in the report, in order to ensure that patients get not just focused medical treatment but all the social support, friendship, follow-up and other things that add to the holistic approach to health. What discussions are His Majesty’s Government having with the third sector in this important area?
To conclude, I thank the noble Baroness and all those who worked on this committee and this report for this excellent and timely debate on emergency healthcare.
Baroness Morris of Yardley (Lab)
My Lords, I am also pleased to be able to contribute to this debate as a member of the committee. I pay tribute to my noble friend Lady Armstrong, who was the inaugural chair of the Public Services Committee and has led it through its first years. Indeed, this report was the last from the committee under her chairmanship. I overlapped with her only on this one report, but I could tell from the time I spent on the committee how much she had done to establish it as a very important committee in our House. I know that there have been a whole series of reports which will add to our debate and our consideration of some crucial issues facing society at the moment. On behalf of all committee members, I place on record our appreciation for the contribution she has made.
I am sorry that this debate is taking place seven months after the report was published. There was never going to be a queue at the door waiting to get in as the debate started, but I hope the appropriate authorities can take note of this.
Governments are always reluctant to use the word “crisis”, as lots of things flow from that. Our committee found that there was a crisis in emergency care, and we used that word. I think we produced sufficient evidence to say that there was a crisis.
Even if you do not take that point, it is interesting to look at the document published by the Government since then, the Delivery plan for recovering urgent and emergency care services, in which they describe what happened last winter and the state we are in. They said it was
“the most testing time in NHS history”,
that there were
“problems discharging patients to the most appropriate care settings”,
and that hospitals reached record occupancy levels. The document also says that patients were spending longer in accident and emergency departments and waited longer for ambulances, and that that has taken its
“toll on staff, who … work in an increasingly tough environment”.
The committee could not match the description the Government themselves gave of the state of the ambulance service and emergency services at key points during last winter. So, whether you want to use the term “crisis” or not, our joint starting point is that things were intolerable last winter and have been intolerable for quite a while. We are not confident that they are going to be any better this winter. To some extent, the challenge for this debate and for the Government now is whether they can use those experiences and the evidence we gave in the report to make sure that things are not as bad next winter and that we can move on.
Lots of things have happened since our report was published, and I want to refer to some of them. It is very difficult, given the time of year and the way the public debate moves on, to know exactly what progress has been made since our report was published in January. I know that some of the figures on waiting times for ambulances have got better. I do not know if that is because of the time of year or because of action the Government have taken. However, I noted with some concern the National Audit Office’s report from June this year. When it looked at recent performance, it concluded that patient access to services for unplanned or urgent care has worsened; that there is too great a variation in service throughout the country; that the NHS has not met operational standards; and that performance has worsened in terms of delays in transferring patients from one service to another.
That is where I think we are. There is joint knowledge and a shared platform of debate that there was a crisis last time, and some of the statistics were very worrying. The one bit of evidence we have from a third party—the NAO report—does not indicate that things are getting any better. The effect this has had on the public, communities and their confidence is well known. It is no exaggeration to say that people lost their lives because this service was not performing at a higher level.
I want to take six points from our committee which struck me, on reflection, go through them and invite a response from the Minister. These are the six areas that stuck most in my mind, and I would like some reassurance that progress is being made on them. First is the immense complexity and connectedness of all the different parts of the system. We talk a lot about the health service and social care and how they do not work together. However, when you look at the emergency services, it is not just those two that have to work together: it is the police and the fire service, and the attitude of the public.
That leads to the second point: it is very difficult to work out who has the ability to effect change. People want to change things. They want to change their bit of the service, but they cannot change other bits. What became evident during the committee’s deliberations is that there is no one leader who can solve the difficulty. That is a problem, but the system itself does not allow people to make changes that have to be made if they are to improve their bit of the service. There has been a really good example of that since our committee’s report was published: the decision of the Metropolitan Police not to attend mental health cases.
I know why the police have done that, because in the committee you would hear somebody tell you that some police officers are spending the whole of their shift sitting in A&E with a person who has mental health problems, whom they have been called to assist. I can absolutely understand why they have said that that cannot happen any longer. I do not believe for one minute that the head of the Metropolitan Police has not tried to solve the problem as well, but I suspect that he has concluded that he cannot get other bits of the system to shift or make the changes in social care, the local authority or the health service—he has to act unilaterally to protect the service that he is absolutely accountable for and responsible for delivering. That is just one example, but that has happened in the last few months. We find so many cases of that, where people knew what they wanted to do to make their bit of the service better but were powerless, because changes needed to be made elsewhere, and the structure that could have brought everyone together to make the changes just does not seem to be there.
My third point, and the point that the noble Baroness, Lady Armstrong, made, was that people are risk averse, and there is very little approach to shared risk. I was pretty appalled to find that some schools, as a matter of policy, called an ambulance every time a child had a head knock, even if the parents were there and were prepared to take their child to accident and emergency. I do not want to belittle the difficulty of taking decisions like that if you are a headteacher or a teacher, but something is wrong there, if mum and dad say that they will take their child to accident and emergency, and the school says that no, the policy is that they have to call an ambulance for every child who bangs their head. We heard similar stories in care homes with patients who had fallen. The public are risk averse to making decisions which on reflection, might perhaps be more sensible.
We see that with 111 services as well. The statistics show that the 111 person is more likely to say to go to the accident and emergency than they are anything else, because there is a risk-averse attitude there. With some of the targets, the attitude to risk is problematic. For those responsible for making sure that ambulances do not wait in the car park at the entrance to the hospital, the best thing to do is to get the patient into the A&E waiting room, because they have then met the target—but it has not solved the problem for the patient, who is now in the waiting room. Others want to get them out the other end, because their target is to get the accident and emergency casualty waiting room down to as few people in it as possible. So they push the patients out to somewhere else, where they wait to go into care or back into the community, and they have met their target.
There are so many instances where people behave in a way that shows that they are not connected to other bits of the service, and they are risk averse. They want to solve their bit of the problem and make sure they can show that their service is performing better with regard to targets. No one actually says, “Let’s put our risks together—let’s put it all together and let’s have some sort of target, which means that I in my bit of the system act in a way that helps you as well as me”.
The fourth point is that one thing that frustrated me, time after time, was that I sat and listened in the committee to the most wonderful pilots going on in different parts of the country. I thought, “Why have we got a problem? Why is anything wrong, because I have just heard the most wonderful example of what is happening?” Nobody knew why it did not happen elsewhere as well. Nobody knew who was evaluating it or who had the power to say that it should happen elsewhere, and that is a problem. So I say to the Government that, while I welcome some of the initiatives that they have announced in recent months—full service virtual wards, transfer of care hubs, and greater flexibility for clinicians—the key thing remains that they are all relatively confined things that are likely to bring about some success.
The key problem for me—and this is where I finish—is that, with the integrated care boards, who is going to make sure that someone can implement the plan that they have been charged with writing up? Could we do more so that the regulators actually make a judgment as to whether services are working together, as well as whether they are working for their own interests? Can the Minister perhaps reflect about whether he is absolutely confident that the people who need to make changes have the power to do so?
Baroness Bennett of Manor Castle (GP)
My Lords, it is a pleasure to follow the noble Baroness, Lady Morris of Yardley, and to join others in thanking the noble Baroness, Lady Armstrong of Hill Top, for this report. I share the reflection that it is a great pity that there is no capacity for people to participate remotely, particularly given that there is a speakers’ list here, so it would be very easy, logistically, to facilitate. This debate does not have the potential difficulties of when there is no speakers’ list. I also join in with the comments about how long it has taken us to get a debate on this.
As others have said, the report came at a point of absolute crisis in emergency services, but there is no real evidence that the crisis has in any way abated. I did not originally plan to, but I will speak from a different perspective that might at first be surprising: the environmental impact of emergency care. The context is that yesterday, my office launched a policy briefing entitled, Eco-directed and Sustainable Prescribing of Pharmaceuticals in the United Kingdom. It was written by my interns, Julze Alejandre and Emily Stevenson, working with Paul-Enguerrand Fady. I acknowledge the financial support of the British Society for Antimicrobial Chemotherapy for that work.
I must admit that, in thinking about the report and the environmental impact of pharmaceuticals and medical devices, I have mostly thought about chronic conditions and treatment in the community and the great deal of discussion about the alternatives of using social and green prescribing—issues that do not apply to emergency care. However, I was absolutely inspired at the launch event yesterday by one of the attendees, a critical care consultant from a foundation trust in the north of England. They said, “Each day, I consider the environmental impact of the treatments that I give my patients in the ICU”. The doctor set out that that meant three steps, or principles: first, choosing the most environmentally friendly route for medical care, which means acknowledging that intravenously administering drugs requires more plastic packaging; secondly, minimising the amount of PPE used by opening only the PPE that is needed; and thirdly, demedicalising by trying to shorten the length of hospital stays where possible, which means less PPE and generally lower consumption of resources in hospital. The consultant told us that these environmental considerations are included in the doctors’ notes and discussed by the healthcare team during the patient handover.
That approach addresses something that we are starting to get some attention and focus on: the fact that, in England, 4% of our total greenhouse gas emissions come from the healthcare sector. There is the impact of plastics, which is increasingly acknowledged, and the pharmaceuticals going into the water supply.
Another of yesterday’s inspiring speakers was Sharon Pfleger from the One Health Breakthrough Partnership in Scotland, a partnership of the NHS Highland, the University of Highlands and Islands, the Environmental Research Institute and the University of Nottingham, which has a £100,000 UKRI Medical Research Council grant. This picks up the point that the noble Baroness, Lady Morris, made about joining up all the issues and all the healthcare bodies, as well as those not immediately related to healthcare, that collectively make up part of our healthcare system. We cannot afford to think, “Here’s the NHS that does healthcare, and everybody else does other things”. This applies in the case of the environment as well as in other things. Looking at the overall aims of the One Health Breakthrough Partnership, I see that it
“seeks to facilitate new knowledge sharing across organisational boundaries, raise awareness of the environmental impact of medicines, and develop novel and robust solutions to complex sustainability issues”.
That joined-up, complexity-systems thinking is an example of what we need to do.
I was reminded of an interview I did recently on LBC. We had been talking for some time about what might be described as the social determinants of health, and how environment helps determine people’s health and whether they will need the emergency care that is now so stretched—meaning everything from mouldy, cold homes to air pollution and all those other issues—when the presenter said to me, “I realised that I invited you on to talk about environmental problems, but you are talking about social problems too. They are all interrelated”. I thought, “Bingo! We have just had a moment of understanding”.
The point I really wanted to make is that, when we talk about healthcare and environment, emergency medicine probably looks like the most distant part—the part where it is hardest to think about the environmental impact. You have an emergency situation in front of you and you have to care for this patient. I think, however, that I have just shared with the Committee a really inspiring example of where individual leadership is really showing a way of operating differently. This is what we need to encourage and evolve. Consultants are, perhaps, seen to have the power to do something like that on their own ward; we need to empower people right across the healthcare system and more broadly to take the steps needed.
To pick up the point made by the noble Baroness, Lady Morris, there are so many good pilots. One of the great institutional problems in the UK is that we have funding for pilots, systems for funding new ideas and people who really clearly see the problem, and who can maybe make a difference in their local trust in their local area, but it does not get rolled out further.
We are the most centralised polity in Europe. Power and resources are concentrated in Westminster and Whitehall. We need to move to a system where the power and resources are held vastly more locally to create circumstances that work for local conditions.
Lord Allan of Hallam (LD)
My Lords, we are all grateful to the members and staff of the Public Services Committee for producing this excellent report and to the noble Baroness, Lady Armstrong, for introducing it. I want to explore five issues that arise from it.
First, I was very much struck by the comments in the report that the waiting times that we get for accident and emergency are calculated using a “dishonest” method. I recognise that the committee was quoting one of the people who had spoken to it. It seems to me that these statistics are so fundamental to our understanding of what is happening with emergency care that I hope the Minister can respond more fully on what is collected and how the data should and should not be used. I note that the noble Lord, Lord Harlech, is here; we have been together sitting through many days’ consideration of the Online Safety Bill and discussing the kind of transparency that we want from online companies. There, the maxim is “more is more”. The more data that we get about their performance, the better. The same should apply here. Certainly, we should be given as much data as possible about all the different aspects of waiting times as one goes through the health emergency care treatment path—the ambulance times, the wait times before you see a doctor in A&E, the wait times from seeing a doctor to being admitted and so on. Then we can make our minds up about whether it is effective. Today, I think we often get statistics that could accurately be described as misleading in the impression that they give.
The second issue that I picked up, which was absolutely fascinating, was a reference to the Frequent Caller National Network, which looks at people who make five or more emergency calls in a month or 12 or more over three months. I also remember an article from the Times Health Commission on 10 June. The journalist Rachel Sylvester had been out with the London Ambulance Service and reported that, in London, 4% of patients account for 22% of demand. The Frequent Caller National Network pointed to a number of reasons why we seem to be getting these frequent callers regularly and the numbers are not coming down. It talked about the lack of mental health support—something that has already come up in the debate and seems fundamental—the lack of primary care support and the lack of NHS system integration. The people manning 999 and emergency care professionals do not necessarily have access to the NHS systems—never mind any other systems—that they would need to direct someone to something more appropriate for them.
I am interested in the Minister’s response to the issues that were identified. Again, we have waited a while to debate the report—the committee produced its evidence last year—but it is very compelling, and I hope the Minister will be able to talk about some actions that have been taken.
Of course, for frequent callers, the real answer is that they can be helped to navigate to the most appropriate care for them. The right reverend Prelate the Bishop of St Albans made an important point about rural services, where, again, we must ensure that services of all kinds, whether mental health support, social care support or primary healthcare support, are available everywhere, otherwise people will default to calling 999 if the service is not there for them.
The noble Baroness, Lady Morris of Yardley, made a critical point about risk aversion. It has been pointed out to me that even if you, as the 999 caller, know— because you have the record—that you are 99% sure that an individual does not need an ambulance, the 1% stops you from directing that person to the service that is the most appropriate. We must have a grown-up discussion about this, otherwise everyone will call 999 and always get an ambulance and always go to A&E, and the service will break down. There must be a better way of thinking about risk than this.
Thirdly, it would be extremely helpful to have a progress report on the emergency care plan announced with great fanfare back in January. I note that Health Service Journal this week carried a quote from someone who said that the approach of NHS England in trying to deliver this care plan by reaching out to integrated care boards and others was like
“whipping the dead horse harder”,
which does not suggest that all is going well in the relationship between NHS England and those who have to deliver the plan. How would the Minister characterise progress on the plan and how confident is he that the capacity will be there for the winter of 2023-24 so that we do not see a repeat of last year’s meltdown?
Again, the noble Baroness, Lady Morris of Yardley, helpfully used the word “intolerable”, which is good because it reflects the public mood. The public in the United Kingdom are generally extraordinarily patient and respectful of the NHS because they believe that it is trying to do its best, but sometimes their experiences mean that even the most tolerant person feels that there is failure. That is certainly the situation we have got to with a number of areas of NHS care, but particularly around emergency care. Even the person most tolerant and respectful of the NHS feels at times that the service offered is intolerable and unacceptable.
Fourthly, we know that a key plank of the recovery plan is to deliver 5,000 more beds. There remain concerns that when the Government said that they would deliver more beds, that was all about surge beds in corridors and other spaces that are in fact unsuitable. I hope that the Minister can update us on the plan for beds so that when we reach the next winter surge they are there. Of course, the long-term solution is for there to be brand new and replacement hospitals but, yet again, we saw from the National Audit Office that the hospital-building programme is falling behind and will not deliver what was promised. I am interested in the Minister’s response to that report, which I think came out since we last debated the hospital programme. It says in terms that only 32 of the 40 hospitals will be delivered by 2030, and even getting to that 32 depends on everything going right in the programme. Sadly, as experience tells us, there is many a slip ’twixt cup and lip, and it will be extraordinary if this hospital programme does not also encounter issues along the way.
Finally, I wanted to raise again the issue of management capacity, which I flagged when responding to the workforce plan. It is an area that we do not talk about as often as we talk about doctors and nurses. I was going to suggest that I had an interest in this area as I once worked as a health service manager, but rather than using “interest” for these things that we once did years ago, the word “affinity” might be better. I have an affinity for people who work in health service data and health service management, who are trying to make the resources that we already have stretch further. This is one area where there seems to be significant scope for that.
However, this depends both on data being turned into information and on information being turned into action. It is very interesting to have a dashboard that shows you how bad things are, but the real value comes in taking that information and feeding it into process improvement. The noble Baroness, Lady Morris of Yardley, reminded us how difficult that can be when you have disjointed services. Somebody sitting there with a police, social services or health dashboard is fine, but the improvement process requires police, local authorities and health all to work together. I would be really interested to hear from the Minister where that capacity is coming from. It is hard work convening people and making cross-service improvements. I would like to hear from the Minister how capacity is being built into data analytics and change management to improve emergency and urgent care.
Finally, I will reflect on a point made by the noble Baronesses, Lady Morris and Lady Bennett, about “pilotitis”; we are good at creating examples of best practice but the real challenge is how to scale it once you have created it. I repeat a call we have made previously to the Minister that he should visit the laggards as well as the leaders and reflect on how we get those bits of the health service that are not so good up to the standards of the really good bits, which I suspect are where his officials mainly take him.
Baroness Merron (Lab)
My Lords, I join other noble Lords in paying tribute to my noble friend Lady Armstrong for her leadership on this very important report. I also thank members and staff of the House of Lords Public Services Committee for taking the initiative to launch this inquiry to investigate the barriers to accessing emergency services, which we have discussed numerous times in the Chamber and will I suspect, sadly, continue to debate. I am glad finally to have the opportunity to debate this important report. As my noble friend Lady Morris justified and reminded us—although she should not have needed to justify it—the committee used the word “crisis”.
Worryingly, the committee argued that there was no sign of an adequate plan or the necessary leadership to address the problems it had unearthed. I am sure that is a concern to the Minister. This is against a backdrop of dangerous waiting times which have meant some 5,500 more deaths in 2022 than we had in 2019. This debate is an opportunity to unpick the Government’s recovery plan, which I will come back to later. It is a step in the right direction, but it is not sufficiently ambitious to ensure that patients are not waiting longer than is safe and the ambition it does have is not sufficiently underpinned by substance.
Several noble Lords have referred to the workforce plan. It was indeed long overdue and still needs substance behind it to make the difference it promises. I highlight that it is not matched by a social care workforce plan, which will always cause a problem for the NHS workforce plan. The key findings of the committee’s report on social care referred to the finding that:
“Unmet need in primary and community care and low capacity in hospitals and social care has left the emergency health services gridlocked and overwhelmed”.
The committee also discovered that when patients are ready for discharge, as my noble friend Lady Armstrong highlighted, there are often waits for community or social care to become available, meaning that beds cannot be accessed by other patients. Demographic change means that this problem in social care is not going away and will get only worse.
We therefore have a problem of a lack of a joined-up approach. I particularly want to highlight that, because my noble friend Lady Morris rightly illustrated that the whole system, which needs to work together, does not work together to allow for positive change. She used a very good example of the Metropolitan Police not responding to mental health call-outs. She was extremely reasonable in how she described it and used one of the many connections that there are: the interface between the police and the NHS. There are so many more, such as the interfaces I have just referred to between social care and the NHS, and between rural and urban, as the right reverend Prelate referred to. I am sure we in this Room could come up with a whole list of interconnecting situations not being addressed in an interconnected fashion. Perhaps the Minister could tell the Committee what work is going on to address this. It seems to me that this is absolutely at the heart of it.
I am also struck that problems faced by the NHS are not exclusive to the NHS. The noble Lord, Lord Allan, referred to frequent callers. Frequent callers are an issue that many other parts of our services are trying to deal with—for example, social services and the DWP. My question to the Minister is: what work is going on across government to focus on dealing with this challenge, which does not recognise boundaries? Of course, people do not recognise boundaries when they make a call for help.
I am sure that the Minister will refer to a delivery plan for recovering urgent and emergency care services, so I have a few questions on that in anticipation of his reference to that point. The plan set out a number of ambitions and one was about patients being seen more quickly in the emergency departments. It gives a new target, which says that there will be further improvement in 2024-25, from the original target of 76% of patients being admitted, transferred or discharged within four hours by March 2024. Can the Minister give us something of a flavour of what further improvement we might expect?
Similarly, the same question applies to the ambition of ambulances getting to patients quicker. The Government have stated that their ambition is:
“Ambulance response times for category 2 incidents will decrease to 30 minutes on average over 2023-24, with further improvements in 2024-25”.
Again, what further improvements might we see?
Certain areas were focused on in the recovery plan. I have a few questions on that. First, in respect of improving discharge, what does the recovery plan’s reference to “strengthening discharge processes” mean in practice? Is this new metric in place currently? What is that new metric and what is its predicted impact?
On funding commitments, there is a commitment of £150 million to build 150 new facilities to support mental health urgent and emergency care services, which, with my simple mathematical approach, means £1 million per facility on average. Are these really new facilities—a question raised similarly in respect of so-called new hospitals? If they are being built anew, how much is the expected cost of running them and is there a commitment to that funding to do so?
NHS Providers made some interesting comments, including that funding needs to be available to deliver change. It also talked about rising demand and persistent workforce shortages, because they challenge targets. I absolutely agree with my noble friend Lady Armstrong that the key enabler for achieving targets is improved patient flow. That runs throughout the whole of this report.
On ambulance trusts, there is a reference to a number of ambulance services—this might fall into the category of good practice to be rolled out elsewhere—seeking to increase the proportion of calls that are closed as “hear and treat”, where there is an appropriately trained member of staff at the call centre to deal with things over the phone. What progress can we expect to see in order for this to increase, and does the Minister consider this a way of dealing with the many challenges?
Finally, my noble friend Lady Morris mentioned the NAO report, which was extremely timely. She referred to a number of concerns raised by the NAO. I will not repeat them, but they bore out the point about the need to improve patient flow. The NAO talked about considerable variation in service performance and access between regions and across different providers, thereby highlighting inequality. As the right reverend Prelate reminded us, a part of that is the challenges faced by rural areas. The NAO also made the point that these various challenges pre-date the pandemic. Will the Government look at the NAO report alongside the committee’s report?
We will see, of course, whether winter pressures are going to be dealt with adequately. This will be an indication of whether the Government’s current plan is going to be helpful. However, my final question to the Minister is, what is his assessment of how the winter will look? I do not want us to get to the stage the committee alerted us to: that when we get to winter, we will have the same problems, only worse. The committee has done an excellent job in giving advance warning, and I hope the Minister and his department will take heed.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Markham) (Con)
First, I add my thanks to the noble Baroness, Lady Armstrong, and all the contributors to the report. It was a thoughtful and constructive report, just as today’s debate has been. I thank noble Lords for that.
Probably one of the benefits of debating the report now, a few months later, is that we have had an opportunity to learn some of the lessons from last winter. I will try to reflect those in my reply. We have also had the opportunity to take on board the evidence from the committee’s report and, as the noble Baroness, Lady Merron, mentioned, the NAO—and, I hope, to reflect quite a few examples of best practice, which I will try to take your Lordships through.
As has featured so much in this debate, I completely agree that this is all about flow. I will try to respond by talking through the flow, because we all agree that that is the vital component.
Of course, the first step of the journey in terms of the flow, as a few noble Lords have said, is demand. We know that as many as 50% of the people going into A&E do not need to be seen there. To me, the first step is how we manage demand and make sure that we treat people in the right place. Of course, that comes in two parts, the first of which is making sure we have sufficient primary care in place, because we know people that often turn up in A&E because they feel that they cannot get the necessary GP appointment. The emphasis we are putting on our primary care recovery plan is very much part of that, as is the direction of travel for the long-term workforce plan—investing much more in primary care and prevention, and having that emphasis versus treatment in hospitals, which is the wrong end of the telescope to be always looking through.
Also we want people to use 111. There will be a complete reset of 111, seeing it as a real navigation tool. Again, as noble Lords have heard me mention a number of times, when we relaunch the app in September, that will be a very important feature, so that people can use the 111 app to establish whether they really need to go to A&E, or whether there is a better place for them to be treated. The other side of this is to establish whether it is appropriate for someone to call 999 and whether they need to be conveyed to A&E. It is about having the right treatment in the right places, and it is all about the “falls” ambulance service, which it is now the responsibility of every ICB to supply. We know that sometimes, you can rectify the situation there and then, set someone right and make sure they are okay, and they do not need to be conveyed to hospital.
It is also about making sure that we have experienced mental health handlers in ambulance services and somebody in the control centre trained in mental health who can help. As for steps in the right direction, we are starting to see the numbers being conveyed go down, which is of course what we want. Whereas 58% of people were being conveyed to A&E a couple of years ago, the current figure is 52%. Clearly, there is more that can be done.
The point that the noble Baroness, Lady Morris, and the noble Lord, Lord Allan, made about the risk-averse nature was absolutely spot on. I shall not pretend that we have proper answers to that, but we need to have a grown-up conversation about it, because we all have very good examples to give. The hope is that the 111 navigation I referred to can help to address that issue, but the human attitude to risk is also a factor.
I turn now to the supply side, response and the ambulances themselves. We are putting more resources into 999, and we are investing in 800 new ambulances. A vital part of that is the discharge hubs for ambulances, so that they are not waiting in the car park with their patients and can instead get back out on the road as quickly as possible. As we know, that is all part of the UEC plan.
Crucial in all this and in managing flows—this links to the point made by the noble Lord, Lord Allan, about data and process improvement—are the flight control systems. As I think I have mentioned before, one of the first hospital visits I ever did was to Maidstone, where they had a fantastic flight control system, managing everything in real time. You knew whether the ambulance was there and whether a person was likely to need a bed; the system looked straightaway at finding that bed and managing the person through the system. What impressed me was that it addressed head-on the often risk-averse nature of clinicians. Amanda Pritchard herself explained the situation to me. She said, “If I were a doctor talking to you, Nick, I’d be saying, ‘I’m pretty happy with how you’re doing, but I’m just going to keep you in one more night to be sure.’” However, when that clinician is armed with real-time data and knows that ambulances are coming and there are people with much greater need of a bed than me, they can make the clinical decision that I am 99% probably going to be fine, and another patient needs that ambulance much more. That is an example of real-time data being used by clinicians, and we are rolling that out as we speak to make sure that it is in place for the winter in 16 trusts. I know that 16 is not 120, but it is a good first step towards that, and I hope we will see improvement.
Carrying on in the flow journey and coming to the beds themselves, we are on target to have a real increase of 5,000 beds in place for the key winter period, as per the question from the noble Lord, Lord Allan. In addition, 10,000 virtual ward beds will be available, with the intention of treating about 50,000 patients per month. That will strengthen everything we are trying to do in terms of the back door, the flow and, as mentioned by many noble Lords, the social care element.
We have started to see the impact of all the things we are talking about. The investment that we are putting into social care is starting to have an impact. As for discharge, right now, we are seeing 2,300 fewer beds blocked, for want of a better word. There is still some way to go; as noble Lords will remember, the target is 13,000, but there has been progress towards that. Our action in terms of the extra money is about learning the lesson around getting the discharge fund out early, instead of suddenly getting to January and thinking, “Oh, we’ve got a problem”. A lot of the social care providers have talked about getting it out early so that they can then plan in advance. Those are all things that we are doing towards that aim. Of course, as many noble Lords have mentioned, underpinning all this is the long-term workforce plan, to make sure that we have cover in the appropriate areas.
Best practice more generally was mentioned in the report and by many noble Lords, and I agree that it is often an issue. We do not have a problem with pilots—I am sure that many noble Lords have heard the quip that the NHS has more pilots than British Airways—but the issue is adoption. I have mentioned a couple of examples of that. We now have tiering in place. The performance of hospitals in each area of UEC is looked at and specific plans are put in place with the leadership to address the tiering. There has been some good progress there, but I agree that, of all the things we need to do, that is definitely a work in progress. On that note, the noble Lord, Lord Allan, will be pleased to know that I am spending the summer visiting hospitals. After the last couple of weeks and those coming up, I will have notched up another 15 or 20 on my visit list. I am definitely trying to get out there.
I really appreciated the thoughtful contribution of the noble Baroness, Lady Bennett. She talked about the environmental impact, and I must admit that it made me think about it in a different way. The NHS recognises that it has a role to play in this. I want to give her a proper response because I was struck by what she said and appreciated her sharing that.
The noble Baroness, Lady Armstrong, mentioned the publication of figures on 12-hour waits. We have been publishing them since February 2023, but there is an understanding of the need for complete transparency in this, as mentioned by the noble Lord, Lord Allan. I know that this is something we are trying to achieve.
The right reverend Prelate the Bishop of St Albans mentioned the rural response. We are looking at each ICB to make sure that they are responding with plans that look after all the needs of their area and where they need more help. We know that it is often hard to recruit people to some of those areas, so there is the possibility of these special incentive payments in order to recruit people to them. As ever, if I run out of time and do not manage to answer everything, I will follow up with a detailed letter.
“Frequent flyers” have been mentioned a couple of times. I saw a very good example the other day of one of the best practices we want to roll out. Redhill is taking its top 1% of “frequent flyers” and getting upstream with them by proactively going out to visit, screen and check them. That has resulted in them needing 30% less treatment. What struck me, and as noble Lords have mentioned, is that one of the first experiences I had as NED in DLUHC’s forerunner was the troubled families programme, which I thought was an excellent example of trying to look holistically at the problem. I wonder—I am wondering out loud with your Lordships—whether we need to look at that more holistic approach for some of these cases; that is one of my takeaways.
As for the NAO report on the NHP, I am still very confident about the 40 new hospitals. The NAO report talked about the original list of 40 but ignored the fact that we have brought in the RAC hospitals. It says that of the original list of 40, we are committing to only 32 by 2030. That is absolutely correct, because we have brought in the RAC hospitals on top of that which were not previously on the list. It is 40—but it is not the same 40 hospitals. That is what the NHP was pointing out, but I think all of us here today would agree that the RAC hospitals were clearly the priority which should have been brought into the list.
The £150 million is new and is a separate part of the budget which I look after as part of the whole capital programme. It will be subject to bids from the hospitals, which need to make sure that they have the revenue to do it.
To conclude on the question on the assessment: yes, I do think there will be improvements next year. Is it going to be challenging? In all honesty, I think it will. I am not going to pretend that there will be one leap and we will be there, but we have a number of measures in place through which we will see step-by-step improvement next year, and, I hope, reflect a lot of the points made in today’s debate on the report.
Baroness Armstrong of Hill Top (Lab)
My Lords, I thank everyone who has been involved today. There are lots of issues that have come up, but I hope that the Minister understands that we saw this as a national emergency. I do not meet anyone now, who, if they begin to talk to you about the health service, does not talk about this as a crisis—being able to see their GP, or getting access to any professional care and reassurance. I could now go into a whole raft of things which he has not mentioned about what we did on “frequent flyers” 15 years ago, and with the group that is the most prevalent: homeless people. We had very clear ways forward, which have all gone.
So, there are issues and lessons in the past. However, the thing the Minister did not address, which I hope he will think about, is whether the Government and Ministers are thinking about what we mean by good emergency care. What should it look like? What should the public therefore expect, and what should the health service—the ICBs, or whatever the structure—be responding to in terms of what good emergency care should look like?
There are huge issues here. This is essentially about the ability of the public sector in its largest window to respond to people’s concerns about whether they will get care when they need it, at the time they need it, and where they need it.
On that basis, I am grateful to everyone for their contribution and I beg to move.