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Westminster Hall

Tuesday 14 May 2002

[Sylvia Heal in the Chair]

Accident and Emergency Provision

Motion made, and Question proposed, That the sitting be now adjourned.—[Jim Fitzpatrick.]

9.30 am

Mrs. Caroline Spelman (Meriden): I welcome the opportunity to debate the important subject of accident and emergency services, and to question the Government on their national strategy. As we witnessed in the tragic events of last week, the national health service is brilliant in emergencies. All the emergency services rose to the occasion in Potters Bar, and for that we are most grateful.

I want to focus on the national picture, but I speak also from personal, local experience. In my constituency of Meriden, the local accident and emergency department has already been radically downgraded. Solihull hospital is a relatively new hospital; it was opened in June 1994 with an all-singing, all-dancing accident and emergency department. In 1997, after the merger with Heartlands, the Minister of State at the Department of Health, the right hon. Member for Barrow and Furness (Mr. Hutton) pledged the future security of services at the hospital, particularly the A&E services. The present Minister was given a copy of that pledge in a letter from my hon. Friend the Member for Solihull (Mr. Taylor).

Over the years, however, doubts have been raised about the future of A&E services at the hospital. When we questioned the Parliamentary Under-Secretary of State for Health, the hon. Member for Salford (Ms Blears), on the strength of that pledge in a debate on Solihull, she said:

the pledge—

I know that my constituents and those of my hon. Friend will be listening closely to the Minister to discover whether that pledge is now worthless.

Doubts were raised about the need for a 24-hour service on such a scale. Ambulances were asked to take emergency cases straight to the sister hospital, the bigger Birmingham Heartlands hospital, because there was no longer an emergency surgeon on duty at Solihull. Solihull was undergoing a downgrading by stealth, and the manoeuvre became a self-fulfilling prophecy. The local hospital trust argued that figures for A&E treatment in Solihull were too low to justify keeping it open, and organised A&E services, including the ambulance service, to make it true.

When local people started to get wind of that, it caused dismay. Dismay has turned into anger, and the issue has become one of the hottest in my constituency. On 25 March, protesters from five other areas of the country that are similarly threatened—Gosport,

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Penzance, Kidderminster, Canterbury and Crawley—marched on Downing street to deliver a letter to the Prime Minister, to which as yet there has been no response. However, the Secretary of State for Health, who received the same letter, did respond. Someone from his Department replied saying that it is a local matter and that it must be addressed with the consent of local opinion.

The question is: what is local opinion? Local people, the potential patients, have made their views entirely clear. It is something that people feel passionately about; to them it is a life or death issue. It can also make the difference between keeping or losing a parliamentary seat, as the Government know only too well from their experience in Wyre Forest. It is not something that the Government can afford to ignore. The Government's response suggests that they do not have a national policy.

Mr. Oliver Heald (North-East Hertfordshire): Is not another interpretation that the Government have a policy of rationalisation, but they are not prepared to admit it and are implementing it by stealth?

Mrs. Spelman : My hon. Friend comes to the heart of the matter. It is the tension caused by the hidden and unpopular policy that we want to bring out today.

I do not want to dwell for too long on Solihull hospital, because the debate is about the national strategy. However, before I move on to that, and with the memory of the Potters Bar train crash in mind, I shall make one further point. Such an emergency could happen in Solihull. There has recently been a huge increase in the area's daytime population, in part because of the new and popular Touchwood centre, which attracts 60,000 shoppers every day from outlying areas. Solihull is also at the confluence of the M42, M40, M5, M45 and the M69, and near Birmingham international airport and the national exhibition centre. One does not want to be a harbinger of doom, but it is as well to be aware of such salient facts when considering decisions about accident and emergency services at our hospital.

My job is to represent my constituents, who have said loud and clear that they want Solihull accident and emergency department kept open 24 hours a day and properly staffed, so that it can deal with any emergency. The local hospital trust may have genuine reasons for believing that that would not be a good idea and that it could not justify restoring the department to full strength on clinical grounds. It may also have genuine reasons for thinking that such an approach would not be in local residents' best interests and that it would not be safe or practical. If that is so, it has not succeeded in making its case.

Mr. Stephen McCabe (Birmingham, Hall Green): The hon. Lady will know that I share her concerns about the hospital. In the interests of accuracy, however, will she confirm that the accident and emergency unit at Solihull has never taken all cases? Paediatric cases, for example, have never gone there since the outset.

Mrs. Spelman : The hon. Gentleman will be aware that, when the hospital opened in 1994, the local

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population collected sufficient charitable moneys for a paediatric ward. At the outset, a full range of services was supplied, but they have been withdrawn over time. Nothing is more shattering for our constituents than seeing the charitable money that they raised for a paediatric ward put to no use.

This issue will not quietly go away. The Government are committing themselves to extra cash for the NHS.

Mr. John Taylor (Solihull): My hon. Friend has come to the matter of resources. Most of the recent Budget was smoke and mirrors, but one thing was clear: heavy Government receipts in the form of increased national insurance contributions from our constituencies will be targeted at national health service provision. Given the opening position at Solihull—including the charitable contributions to it—and the enormous amount that is now being raised through national insurance contributions, is it not clear that we should resource 24-hour accident and emergency provision at the hospital, which services our constituencies?

Mrs. Spelman : My hon. Friend comes to the same conclusion as I: extra money is being raised specifically for health, and constituents want additional resources to be spent on keeping accident and emergency units open 24 hours a day. That is the message that they want the Government to get loud and clear from this debate. If it is not feasible to fund such a service, the Government must properly explain why, and make the experience of going to Solihull's sister hospital at Heartlands more pleasant and convincing.

I must, however, move on to the wider issue of accident and emergency strategy as it affects the country generally. In their emergency care report, which was updated in April, the Government produced a plan called "Reforming Emergency Care: First Steps to a New Approach". At this stage in their term in office, however, such an approach is a little tentative. People want improvements that they can see now, but the report reads a little like a wish list, with targets such as:

I picked that example almost at random, but the paucity of the ambition is striking. Anyone who has had the misfortune to use a typical accident and emergency facility in a large hospital knows what an unpleasant experience it can be, yet the goal is to reduce a patient's wait to four hours in two years' time. Surely another model for dealing with accident and emergency admissions should be studied and taken on board.

In a previous debate, which was specifically about Solihull hospital, I brought to the Minister's attention the findings of a working group of the Royal College of Physicians. The group's radical proposals reversed current thinking, and advocated that accident and emergency facilities be no more than 10 minutes away from the patients that they serve. I commended that report for consideration by the Government some while ago.

The Government also refuse to believe that any system in any other country is worth studying and learning from. Their report notes that the NHS is second

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to none in responding to major emergencies, and I have applauded that fact. To be fair, however, the report also admits to failures in the system. Under a general heading, it deals with patients having to wait too long from care to treatment at each stage of the emergency care system. It starts with the time that it takes to get an appointment with a general practitioner, and goes through to inadequacies in the system that compound delays, including the notorious bed-blocking scandals with which we have become familiar.

The report offers various solutions to those problems, but no radical approaches. The main recommendations are for more money to be allocated, but within the same system. I am passionately committed to the ideals of the NHS, but that does not mean that better practice elsewhere cannot be incorporated into the service. The Wanless report found that accident and emergency departments in Germany, for example, see patients in a couple of minutes—we can dream on.

The report claims that things have improved and that, for example, nearly 80 per cent. of all accident and emergency patients spend four hours or less in A&E units. I checked on Heartlands hospital, to which our constituents are now sent, but the latest figures tell a different story. Some 74 per cent. of patients are seen within four hours, which leaves 26 per cent. waiting for longer, and I have heard of waits of up to eight hours.

Those figures are backed up by the Audit Commission's report on A&E waits, which was published in October 2001. In 1996—an important reference year—89 per cent. of patients were admitted within four hours, but the figure had fallen to 76 per cent. by 2000. The percentage of patients seen by a doctor within an hour was 73 per cent. in 1996, but 53.5 per cent. in 2000. So, despite the Government having been in power for five years, the situation has got worse.

The anecdotal evidence is also far from happy. Ambulances must often queue outside Heartlands before even an initial admission. Once there, patients find that the conditions are crowded and impersonal, which is not conducive to helping people who are in pain and distress. Ambulance crews are, however, subject to a local protocol. A letter that I have just received from the West Midlands ambulance service states that, in respect of

That will continue unless, of course, those responsible are confronted by people power.

A local councillor has told me that ambulance drivers are increasingly meeting fierce opposition when trying to take patients to Heartlands. One ambulance crew was on its way to admit an elderly woman who was having her cataracts removed at Heartlands—that, in itself, was a strange decision—but she demanded to be taken to Solihull. Eventually the ambulance men allowed her to contact her consultant, who agreed with her request to have the operation in Solihull hospital, and that is where she was taken.

I secured this debate partly because certain questions have still not been answered.

Mr. Julian Brazier (Canterbury): My hon. Friend is delivering a powerful oration, and the pattern that she

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describes is, sadly, repeated elsewhere. There is pressure on ambulance crews to take people not only from Canterbury, but from a range of settlements in east Kent, to the Kent and Canterbury hospital, where the number of beds has been reduced. Crews face pressure when they try to take people to other hospitals, which are being expanded.

Mrs. Spelman : My hon. Friend gives another example of downgrading by stealth. We want to bring that issue into the open today so that it can be properly debated.

In a written question, the Minister of State, Department of Health, the right hon. Member for Barrow and Furness was asked how many nurses are employed in accident and emergency departments in England. His response was:

The emergency care report says that the number of nurses working in accident and emergency will increase by 600 by 2003. That seems a little delphic in the circumstances. Asked about both ambulance response times and the proportion of patients seen by a doctor within an hour of arrival at accident and emergency in the last six years, the answer was the same:

That all seems a bit haphazard. For the Government to have an effective national accident and emergency strategy, the figures must be collected centrally. Otherwise, how do the Government have any idea whether targets are being met?

There is also the matter of what constitutes an accident and emergency department. In some local hospitals—such as Solihull—it is proposed that accident and emergency departments should be run by specialised nurses who are able to treat minor accidents and emergencies. However, that is not the public's perception of an accident and emergency service. Clinically, doctors would argue, that might be the way ahead; but that is where the public and specialist medical opinion seem to part company.

In preparing for the debate, I consulted the independent organisations that represent accident and emergency specialists. They took a pragmatic approach. They told me that having an all-singing, all-dancing accident and emergency department in every town was what the public wanted—they are aware of the demand. However, it is not clinically safe, given the number of available doctors, staffing restrictions and the Government's strategic direction. As an analogy, Ian Anderson, who is president of the Faculty of Emergency Medicine, said that keeping an under-staffed, under-qualified accident and emergency department open would be like a shopkeeper using all the staff to serve customers in the front of a shop and no one to replenish the stock behind the scenes. It is difficult to get away from the fact that there is a constraint because of the lack of adequately qualified doctors. However, the Government have been in power for five years and the matter could have been tackled at a much earlier date.

The jury is still out in Solihull—there is a formal consultation process to go through—but strength of opinion is running high. We must listen to expert

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independent opinion in order properly to inform the debate. However, as politicians, we must also listen carefully to the wishes expressed by our constituents. Ultimately, they fund this public service provision.

Given that we are considering plans for the future of a service that is of vital importance to my constituents and to those of other hon. Members—many of whom will speak in the debate—the Government's report and some of the debate in Parliament can seem far removed from reality. The bottom line is that unless the people who actually use the facilities are happy with them, they are not working and all the wish-lists, reports and vague promises made by the Government will cut no ice.

Councillor Don Blake, chairman of the health service monitoring sub-committee in my constituency, is waiting for answers to the following four questions. Why, unlike coronary heart disease, services for older people, mental health and so on, is there no national service framework for emergency care? How do the changes at Solihull hospital fit in with the wider plans for accident and emergency provision within the Birmingham and black country strategic health authority? How will the proposed changes affect accessibility to accident and emergency in our part of the west midlands? How do ideas about accident and emergency fit in with plans for the long-term development of Solihull hospital on the principle of one hospital on two sites?

If those questions are not answered satisfactorily, people will increasingly take power into their own hands by protesting or forming action groups or, like my constituent, by blind refusal to adhere to protocols that seem to ignore patients' wishes.

9.49 am

Mr. Peter Viggers (Gosport): This is a timely debate, because thinking about accident and emergency units is changing. The old thinking was that every accident and emergency unit should be part of a major hospital where every specialty was available because, for example, a child might be brought in who needed paediatric care or specialist treatment such as vascular surgery might be required. If every specialty is offered, it is not just a matter of having one consultant; three or four must be available in order to provide 24-hour cover.

There was also a strong feeling among the royal colleges that there could be no joint-site working. The consultants had to be working at one hospital in order to get accreditation. Doctors and nurses could not be accredited if they were working in smaller hospitals with no leading consultants available to advise them. For all those reasons, the old certainty was that an accident and emergency unit could only be part of a district general hospital. Increasingly, across the whole of the country, accident and emergency units have been closing and specialisation has been focused on the larger district general hospitals.

That model—very large district general hospitals with accident and emergency units—has proved to have significant disadvantages. The first is that not every patient who is taken by ambulance to the accident and emergency unit at a large hospital some miles away needs to go there. A significant proportion of those who are taken on the blue light into the large, distant, district hospital prove not to require its care. The problem then

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is what to do with such patients. Either they have to be sent back to local hospitals, or they have to be admitted and it is difficult to discharge them because—for reasons known to medical science but not to non-specialists—district general hospitals and local hospitals have different cultures and it can be difficult for a district general hospital to discharge patients to the local hospitals.

Secondly, because of the Government policy of tightening regulations on nursing homes, fewer nursing home beds are available, so suitable patients cannot be discharged from district general hospitals back into the community or to local care centres.

Medical and technical advances now enable diagnosis to be made at a distance; telemedicine has advanced considerably. In my constituency, the Royal Hospital Haslar treats patients around the world through telemedicine. The armed forces cannot have leading specialists available in every area served by their personnel. Telemedicine allows specialists to advise on patients in Cyprus, Bosnia or Sierra Leone. Such advances also make it possible to treat patients in local hospitals rather than taking them all the way to a district general hospital. There can be considerable advantages in taking a patient quickly into a local hospital. In medicine, the priority is often not to have long-term highly specialised care, but to stabilise the patient, particularly in a cardiac case. Once the patient is stable, he or she can be moved in comfort to a larger hospital where specialist care can be administered.

The final reason why the old model of large accident and emergency units attached to district general hospitals has proved to be disadvantageous is the one that has been spelled out so well by my hon. Friend the Member for Meriden (Mrs. Spelman). People do not want it. They want their medical care to be provided as locally as possible, because an extremely important part of medical care and well-being is the opportunity for family and friends to visit. People do not want to run the risk of lying in the back of an ambulance that has to make its way through busy traffic to a district general hospital some miles away. They want medical care to be provided locally.

Therefore, plenty of thought is being given to a new model. The Parliamentary Under-Secretary of State for Health, the hon. Member for Salford (Ms Blears), is kind enough to nod at that. The word "reconfiguration" prevailed during a meeting of residents from Gosport who came to see her. The reconfiguration of our medical care is being given much thought, to see whether further medical care can be provided locally and through telemedicine and split-site working. The idea of specialists working in more than one hospital was thought to be unpopular. Certainly, the Royal College of Surgeons was opposed to it at one point, but increasingly specialists are aware that good medical care can be provided through split-site working, with some provision made in one hospital and other specialist experience provided in another. Reconfiguration can lead to improvements in medicine.

I shall apply those general arguments to my local case. On 10 December 1998, a date never to be forgotten, the Government announced their proposal to close the Royal Hospital Haslar in my constituency. It is and has

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been the only Ministry of Defence hospital, but a committee in the Ministry of Defence that included no one with any medical skills decided to close it. To put it mildly, there was disagreement locally. We formed the Haslar task force and the "Save Haslar" campaign, which I have chaired since its creation. We thought that our rally and march would attract only a few hundred people, or perhaps a thousand or two, but 22,000 came to demonstrate their concern about the retention of Haslar hospital. It is thought by the House of Commons Library to be the largest demonstration ever in support of a hospital.

The official plan for Haslar—hon. Members should suspend their disbelief—is to increase the number of out-patients from 55,000 a year to 60,000. A new accident treatment centre is now available there for suitable patients, and the hospital has recently been nominated as the new diagnostic and treatment centre for south Hampshire. That will involve some of the best operating facilities in the United Kingdom. The official plan says that all those advances and improvements will happen and that Haslar will close in 2007. It beggars belief to suggest that the closure of such superb facilities makes sense, but that is the official policy.

We are working in the right direction. The accident treatment centre is a good step. The diagnostic and treatment centre will be an extremely valuable facility to reduce waiting lists for cold surgery, and the increased use of Haslar for out-patients is fine. We agree with all those steps, but we do not agree that the hospital should close in 2007, when the nearby Queen Alexandra hospital at Cosham is rebuilt under private finance initiatives.

We hope and believe that plenty of support will be given to the retention of Haslar and the continued use of its site and outstanding facilities, including the operating theatres and telemedicine equipment. We want to encourage the use of the accident treatment centre and expand the range of emergency medical conditions that can be referred to it. Also, we want a fundamental review of the plan to close Haslar after 2007. It makes no sense, and we want to give Haslar the certainty and confidence that it needs for the longer term by confirmation that the hospital will remain after 2007.

I have not yet referred to defence medical services. There is no doubt that Defence Costs Study 15, which reduced the number of hospitals in the defence medical services from four to one, dealt a blow to the service and a blow to the morale of those who work in it. However, that was nothing compared with the decision to close Haslar. In the key specialties of general surgery, orthopaedic surgery, anaesthetics and general medicine, there are now gaps in the establishment as high as 75 per cent. In other words, in some of those key areas, there are only a quarter of the required number of specialists. There is no doubt that if the armed forces were deployed in strength, their capabilities would be restricted by the inability to provide adequate medical back-up. That is extremely serious from a defence point of view, so I hope that, for that reason, as well as for the support of the local civilian population, the decision to close Haslar will be reviewed.

10 am

Mr. Stephen McCabe (Birmingham, Hall Green): I begin by congratulating the hon. Member for Meriden (Mrs. Spelman) on securing the debate.

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I very much agree with the hon. Member for Gosport (Mr. Viggers) about the need for earlier assessment of patients and greater or more flexible use of available resources. It strikes me that that will be one of the major shifts in medicine in future. When the hon. Member for Meriden was telling us about the origins of Solihull hospital, I reflected that, had we known what medical provision would be available, we might have looked differently at how we configured all our services, although that is not a criticism of what was done when Solihull hospital was built.

I shall give one simple example. In my constituency in south Birmingham, we are examining proposals for a new medical centre at Green Bank, combining several GP practices. If it is successful, it will provide several localised services for people in Hall Green and, I suspect, for some people in Solihull, including provision for minor day surgery. That will assist people who would previously have gone to hospital. In that context, any future plan for A&E provision should have a national element but should also take account of local considerations. I should be interested to know what the primary care trusts in the area are proposing, so that we can consider their proposals in the context of the overall provision of hospital and other medical services.

I share the concerns that have been expressed about Solihull hospital. I have been at pains to establish with the trust authorities that there are no plans to close the hospital. I am reassured on that front because I understand that about two thirds of the population of Meriden, Solihull and Hall Green currently use the hospital, and that is unlikely to change. There is tremendous scope for joint-site working, and I am not sure that the trust authorities have considered that as seriously as they might. With the advent of telemedicine, there is much greater scope to share key personnel, and I hope that that, too, will be carefully considered. However, I am aware that the trust claims to have advertised at least 11 times for senior house officers and is having some difficulty attracting staff. I would not want, in pursuit of any campaign to defend a local service, to ignore a reality such as that. The hon. Member for Meriden referred to issues of clinical safety. Much as I want to protect and defend local services, I would personally find it extremely difficult to take the risk of sending someone to a unit where the level of treatment could not be guaranteed.

Mr. John Taylor : Does the hon. Gentleman agree that it is perverse to expect recruitment of high-quality personnel to the accident and emergency facility at Solihull hospital when ambulance crews are under strict instructions to take patients to Heartlands hospital? It is a self-fulfilling prophecy. If nobody goes there because ambulance crew are instructed not to take them, who will apply for a job there?

Mr. McCabe : It depends where we start with that issue. If the plan starts with a decision to downgrade a unit and to instruct ambulance crew not to take patients there, the hon. Gentleman is right. However, if there is already a shortage of key medical personnel and that gives rise to some level of clinical risk, and in individual cases judgments are made to take people elsewhere, that is a different matter. It will take some time to recruit the additional doctors and nurses that we need. In the

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meantime, my instinct is that the trust should consider making greater use of the existing personnel across the sites. We should make the best use of the facilities that we have.

Mrs. Spelman : I am grateful to the hon. Gentleman. I am sure that he is aware that the previous management had an arrangement to rotate its doctors between the two sites and secured the agreement of the royal colleges for that to be acceptable for accreditation. With a change of management, that appears to be no longer possible. Does the hon. Gentleman accept that the emergency surgeons were removed without any consultation with the public? That had a massive demoralising effect on the accident and emergency staff, who saw their department's remit being downgraded before their very eyes.

Mr. McCabe : I hope that I have made it abundantly clear that I think that there should be greater sharing of staff. That seems a perfectly reasonable way to proceed. However, we should also achieve a balance between the level of treatment and the skill of the personnel available. If I were making a judgment on behalf of an injured friend, that factor would weigh on my mind.

Mr. Heald : Is the hon. Gentleman really saying that recruitment difficulties are sufficient reason for downgrading or closing A&E departments? If so, that would make the situation difficult in areas such as my constituency in Hertfordshire. The area is very expensive and it is difficult to recruit, but we still need our A&E departments.

Mr. McCabe : The hon. Gentleman misunderstands me. I am saying that where there is a shortage of key personnel, the judgment must concern how we use the resources at our disposal. It would be ludicrous to argue that a facility should be kept open and available all the time if there is doubt about levels of clinical safety. That would be absurd and I cannot imagine any constituent signing up for it. My understanding is that people want good local services as close as possible to their immediate environment, but they want to balance that with the level of safety and treatment that they would reasonably expect. That is all that I am saying.

Dr. Andrew Murrison (Westbury): The hon. Gentleman's point is important. My understanding is that he is suggesting that we should have a geographically two-tier NHS: in areas where it is relatively easy to recruit staff, we should have the kind of provision that we expect at the moment, and in areas such as that represented by my hon. Friend the Member for North-East Hertfordshire (Mr. Heald), we should pragmatically reduce the provision because we do not have the staff. That seems a rather bankrupt philosophy, to which I hope that he does not genuinely subscribe.

Mr. McCabe : The hon. Gentleman has either misunderstood me or is talking about a personal fantasy, because I am not saying that at all. In areas where there are staff shortages, we should maximise the use of the existing provision as flexibly as possible. On occasions, that may mean that establishments must share doctors. We all want acceptable minimum standards that apply throughout the country.

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The hon. Member for Meriden told us that Labour has been in power for five years, which no one is disputing. However, as Stephen Thornton, the former chief executive of the NHS Confederation, said, the health service experienced decades of underfunding before that. The question is whether the new investment proposals and the direction suggested by the Wanless report will provide the route to improving the long-term efficiency of our health service for everyone, or whether we should switch to an as yet unspecified alternative, which the hon. Member for Meriden flirts with but will not spell out. Until we know what that alternative may be, we have to wonder at the crocodile tears that the Opposition are spilling over the health service.

Mrs. Spelman : Would the hon. Gentleman accept that any party in opposition has the perfect opportunity to consider the statistics and the question of supply and demand and plan for the changes that it wants to make? It does not have to wait five years until it is in a position to implement changes.

Mr. McCabe : I make three obvious points in response. First, the hon. Lady's party has a history of trying to destroy the health service. Secondly, the Conservative spokesman on health has admitted that he has a stealth plan to wreck public confidence in the health service. Thirdly, it seems absurd for the Opposition to refer to alternatives if they are not prepared to disclose to the public, in the interests of allowing them to make choices about health, what those alternatives are and how much they will cost.

My final point for the Minister is that we need to strike a balance between what is locally viable and desirable and what resources can be used, set against a national framework for A&E. Will the Minister tell us how the Commission for Healthcare Audit and Inspection will work on that problem? Recently, there was a dispute about the long-term future of heart transplants at the Queen Elizabeth hospital in Birmingham, and at other hospitals. The resolution of that dispute came in setting standards to be monitored by the Commission for Health Improvement, so that services could be provided on the basis that treatment would be safe and reliable. Some similar guide to the operation of A&E treatment centres and units would be useful.

10.13 am

Dr. Richard Taylor (Wyre Forest): I thank the hon. Member for Meriden (Mrs. Spelman) for securing the debate and for referring to a national strategy. We must consider the national outlook for A&E provision before we relate it back to our own areas.

My presence in the House is entirely due to the importance that local people put on A&E services. People are prepared to travel for high-powered elective or emergency treatment, but not for bread and butter emergencies. If they live in or move to an area with local emergency services, they do not expect them to be taken away.

As the hon. Member for Gosport (Mr. Viggers) said, recognition is coming for local people's priorities. The first glimpse of that recognition came with the Scottish review of acute services in 1998, which states that

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As recently as May last year, the Northern Ireland acute services review tackled the question of A&E. The report suggested that there should be three grades of A&E. Of course, we cannot all have the top grade—the all-singing all-dancing provision for major head injuries and major chest and cardiac surgery. The second grade is represented by the sort of A&E department that commonly exists at the moment, which does not deal with the major procedures. The third grade is lower, but is more than a minor injuries unit because a doctor is always present. In Northern Ireland, they have begun to consider making some sensible alterations.

After last year's general election, the Royal College of Physicians realised that there must be a rethink and, along with the Nuffield Trust, began to consider a model that would keep emergency services local in the first instance. A lead article in the BMJ from 4 August 2001 sums up the situation when it states:

that is, emergencies going locally first—

We were tremendously helped by the admission from Sir George Alberti, the president of the Royal College of Physicians, that medicine could exist without surgery. That made a huge difference, as most emergency services are medical.

The greatest step forward, however, is contained in the Darzi report from County Durham. Professor Ara Darzi is part of the NHS Modernisation Agency, so he speaks with authority. He takes into account local and staffing issues and what it is and not possible to achieve.

Country Durham and Darlington have three acute hospitals between them: in Durham in the north, Bishop Auckland in the middle and Darlington in the south. The Bishop Auckland hospital is the smallest, is 12 miles from Darlington and 13 miles from Durham, and serves a population of less than 40,000. Clearly, it would not be possible to run all services at Bishop Auckland, but Ara Darzi's suggested model includes a doctor-led A&E service and most of medicine, along with a diagnostic and treatment centre, which is a modern idea that has much to commend it as it separates much elective surgery from the emergency work that blocks beds. Such a model might be applied to many hospitals that are under threat.

Mr. Brazier : Will the hon. Gentleman confirm that he is basically talking about an A&E with everything except major trauma facilities?

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Dr. Taylor : The details of the facilities in each area would be decided according to local opinion and decisions. I shall return to that later, as it is the most important point of all. As I read it, the Darzi model would not be exactly the same in other places, but it gives a flavour of what is possible with medical staffing and local desires. It is incredibly important.

Something has to be done politically, as my presence in the House shows. Far more importantly, something has to be done for the patient. The three A&Es in Worcestershire have been reduced to two, and I have received many letters that suggest that that change is not working. I could talk for many hours about trolley and ambulance waits, staff stress and ambulance distances, but I will not. However, I will give one fact. Before the downgrading of facilities in Kidderminster, the monthly mileage of the Wyre Forest ambulance service was 8,000 miles, but is now 24,000 miles. Change must take place, and it could be made on the Darzi model.

I shall end with some pleas to the Minister and her colleagues, the first of which is that they consider the Darzi model.

Mr. John Taylor : The hon. Gentleman is talking about the Darzi model, based on the views of that expert gentleman. Did he say that the hospital in Bishop Auckland served a mere 40,000 people? Did I hear him correctly?

Dr. Richard Taylor : That is the population of the town, but the hospital serves a large rural area, which makes the population that it covers much greater. We would see from a map that Durham, Bishop Auckland and Darlington are on a north-south line. The people in the country to the west will not be that much further from Durham to the north than Darlington in the south. The Darzi model must be considered as a blueprint for a national strategy.

I was grateful to the hon. Member for Meriden for mentioning the Secretary of State's response. On the Floor of the House, he told me that local matters must be decided by local opinion. I ask that that be the case, without pressure from the Department of Health and its Ministers. Makers of local opinion—that must include citizens as well as members of the professions—should be given freedom.

Dr. Evan Harris (Oxford, West and Abingdon): Given the democratic deficit in local decision making on the health service, does the hon. Gentleman accept that there is some merit in still being able to refer significant changes such as hospital closures to the Secretary of State, because it means that someone in an elected position takes responsibility for the result of policy or the general financial picture? That is perhaps the only merit of referring such decisions. I say yes to local decision making, but we have to make it more accountable if we are to dispense with the taking of responsibility by politicians elected at a national level.

Dr. Taylor : I could not agree more that there must be local accountability. That is why I am desperately sad that it seems that community health councils, which have some democratically elected members, will disappear. I believe that the Government are sincere

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about trying to involve local people in decision making. I remind the Minister that she wrote in a letter last September that

If my pleas are heard, crises will be avoided, and in Worcestershire, the devastation of hospital services forced by the now abolished health authority could be undone and repaired.

David Taylor (in the Chair): Before I call the next speaker, I should tell the House that I intend to call the Liberal Democrat health spokesman at 10.30 am. I call Dr. Murrison.

10.24 am

Dr. Andrew Murrison (Westbury): I am grateful for the opportunity to speak in this timely debate. The tragic events of last Friday have highlighted the importance that we place on front-line services and there is no doubt that casualty departments are at the forefront of the national health service. I pay tribute to the dedicated professionals of Barnet general hospital.

The six months that I spent as a senior house officer in the accident and emergency service were the most exhausting months of my career, but they were some of the most fulfilling. I am sure that other hon. Members here today who are medically qualified would share those sentiments. My hon. Friend the Member for Gosport (Mr. Viggers) raised the subject of telemedicine at the Royal Hospital Haslar and I remember offering medical advice to patients many thousands of miles away during my time as a casualty officer in that hospital. I agree with absolutely everything that my hon. Friend said.

I know that the Royal United hospital at Bath that serves many of my constituents has recently been taxing the minds of Ministers. However, if we set aside end-of-year deficits, suspensions and fiddled waiting lists, we are left with a hospital that provides a remarkable service to my constituents in Wiltshire. Nowhere is that more apparent than in the hospital's casualty department.

The Minister is a keen admirer of community health councils, so she will be delighted to note that our debate coincides with a meeting of the RUH standing group of the Bath and district community health council. As luck would have it, the council is debating as we speak the hospital's accident and emergency department, and particularly the council's recent survey of patients and carers attending the casualty department. The survey gave people the opportunity to comment on a raft of issues, with 35 detailed questions on issues such as travel and car parking, A&E waiting times, and the support given to patients and carers on discharge. I regret that our debate and that meeting are simultaneous, as it prevents me from conveying the council's findings, which I know will be illuminating.

While we can, we should draw upon our community health councils because, if the Minister has her way—I hope that she will not—they will shortly fall silent. Today's CHC agenda is a treasure-trove of useful activity. We learn for example that the council will participate in the nationwide casualty watch exercise on 20 May. There is a detailed critique of the plans for a

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new casualty dept in Bath; and the CHC asks several questions. It asks about the drop-off car parking facilities for the unit; we should remember that the hospital serves a vast rural area, so it is extremely important for those of my constituents who have to use the hospital. It wants to know whether the toilet facilities are adequate, and particularly about access for disabled people. It also asks whether the bereavement suite is fit for the task and whether its relationship to the mortuary is sympathetic. Those are down-to-earth questions, which planners forget and neglect—particularly planners of casualty departments—but community health councils give a powerful voice to local people on such important matters.

The council has been advised that it may not be possible to change the plans on which it has commented without causing undue delay or expense. What a shame that is, because it is a useful catalogue of concerns from an organisation with its ear to the ground. It is a shame that those comments were not used to inform the decision-making process at an earlier stage. The NHS machinery appears to be running down our community health councils already. That is lamentable in the extreme, but what a fantastic demonstration it is of the value of community health councils. I know that all Conservative Members will join me in condemning the Government's plans for closing community health councils and for proving completely recalcitrant to the wise words of Conservative Members, during the Committee stage of the National Health Service Reform and Health Care Professions Bill, that CHCs should be reformed, not abolished.

Last year, I attended a major accident on the A36 in my constituency, in which four people lost their lives. I saw at first hand the superlative quality of our emergency personnel. The weak link is a system that obliges ambulances in certain parts of the country to stack up outside casualty departments, waiting to discharge patients, like aircraft at Heathrow, or to circle district general hospitals like planes on a holding pattern. Is anything more likely to demoralise all the health care professionals involved? Despite the best efforts of our health care professionals, the NHS front-of-house is in crisis. It is no wonder that community health councils feel obliged to take a special interest and that the Government are hell-bent on silencing them.

10.30 am

Dr. Evan Harris (Oxford, West and Abingdon): As the hon. Member for Wyre Forest (Dr. Taylor) said, we are all grateful to the hon. Member for Meriden (Mrs. Spelman) for giving us the opportunity to debate some of the wider issues beyond individual hospitals. We heard an interesting debate between the hon. Member for Birmingham, Hall Green (Mr. McCabe), who made some valid points, as well as some contentious ones, and other hon. Members.

I remember meeting some of the staff at Solihull hospital and noting their concern, and that of local people, about its downgrading. Indeed, this weekend, I visited West Cornwall hospital in the constituency of my hon. Friend the Member for St. Ives (Andrew George), who cannot be with us today, which drew my attention to the fact that threats to the provision of local services

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occur in rural areas as much, if not more than, in urban and suburban areas. I know that the hon. Member for Gosport (Mr. Viggers) has been active on the issue of Haslar hospital, along with my hon. Friend the Member for Portsmouth, South (Mr. Hancock) and the hon. Member for Portsmouth, North (Syd Rapson), so many campaigns are cross-party. I know of the work done by the hon. Member for Canterbury (Mr. Brazier) in relation to the Kent and Canterbury hospital, which I have also visited. It is remarkable that many of those hospitals are not found in the constituencies of Labour Members. Indeed, Bishop Auckland general hospital, which is due to be reprieved from threat because of its size, is in the middle of a Labour constituency. It is questionable whether that is a coincidence.

As the hon. Member for Meriden said, much stealth and shifting the blame is involved in the closure of hospitals. We touched on that issue in our discussion about whether decisions are truly local. If decisions are to be made locally, they must be democratically accountable. Governments, who generally seek to centralise praise and decentralise blame, like proposals to be led by local managers, who can be, and all too often are, demonised, although the buck should stop with the politicians who make policy decisions. In relation to the health service, that means Westminster politicians, including those who make the financial decisions. It need not be that way, but it is. Until we have an accountable tier of politicians helping to run the health service on a regional and local level, politicians at Westminster will rightly continue to debate such issues and the Minister and her colleagues will be held responsible.

Hospitals are being closed by stealth, bit by bit. First, one part of the service is lost, and that is deemed to make another part of the service unsustainable. If we are to have an open approach, we must ask the Government, through their proxies—the local managers who come up with the proposals—to set out a clear plan, which can be debated, at the outset. We know that many closures are financially driven and hidden behind allegations about the need to provide a safer service. The issues at stake can be directly financial, as they were in Worcestershire, where closure was required to fund a private finance initiative, or financial by proxy—a shortage of staff may well be related to the inability of successive Governments to fund the necessary consultant expansion.

Financial decisions are hidden behind issues related to the working time directive and junior doctors' hours. I used to work in that field as both an expert on a national basis and an employee on a regional one. There was no problem with junior doctors' hours that could not be solved by the adequate provision of a consultant-led service, with the training and the creation of new posts that go with that.

Those who make the point that patient safety is the key issue must provide evidence. Our approaches must be evidence-based. It is not just a question of the provision of adequate back-up and specialties leading to a safer service. There is also the issue of travel time for casualties going to hospitals. If all small units are to be closed, we have to balance the alleged safety gains of that measure against the worries about increased transit time for people who are not yet stabilised.

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It is not sufficient for decisions on patient safety to be handed down from on high without adequate debate and scrutiny. Such scrutiny needs to be much more explicit. Reports produced by the royal colleges are informed by expert opinion, but have baggage attached to do with the working patterns of consultants. They need to be debated. They should be published, and the basis on which they are formed should be scrutinised. We need elected politicians to take responsibility, preferably locally.

We must remember that safety has many aspects. It was not a lack of access to surgery that caused the disasters in Bristol, but too much being done by specialists beyond their competence and with insufficient regard to the suitability of patients for particular procedures. That is one of the best examples of a failure of patient safety. It arose not from inadequate medical cover, but from too much medical interference.

When we consider the staffing problems that underlie some of the stresses placed on smaller hospitals, we must recognise that we are dealing with the legacy of underfunding, which lasted until at least 1999. Medical staffing levels were determined by a decision taken not by the previous Conservative Government, but by the last but one. The failure to invest in medical schools and medical student numbers in the early 1980s and the failure of successive Governments to expand the consultant grade—

Mrs. Spelman : Is the hon. Gentleman aware that, perversely, there is a wave of redundancies in our medical colleges, at precisely the moment at which the Government claim that they want to increase the number of students?

Dr. Harris : We need now to be at the point at which the Government claim we will be after five years of expansion of medical schools. That expansion will produce the junior doctors needed to staff the departments, but a shortage of junior doctors is only partly due to a shortage of newly qualified people. There is also a shortage of consultants to provide the training opportunities upon which responsible expansion of junior doctors' posts is based.

It is no good creating new senior house officer posts and sucking people in from South Africa or Australia if no adequate training is to be provided. That is why the provision of adequate medical staffing begins and ends with expanding the provision of consultants. I have said that again and again, but until very recently there has been a complete failure to increase the number of consultants.

I entirely agree that small hospitals can be supported in the provision of senior house officers by rotation through larger hospitals. It happens in Banbury in my constituency, with rotation from the Radcliffe infirmary, and it happens in Solihull. It should be a question not for local hospital managers but for the postgraduate deans charged with ensuring adequate training. The neutering of those deans by service-driven reforms to medical work force planning—introduced by the previous Government and added to by this one—has damaged flexibility.

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Dr. Murrison : Will the hon. Gentleman give way?

Dr. Harris : I do not have much time. I come finally to accident and emergency departments being treated as scapegoats in relation to waiting times. If those are anybody's responsibility, they are not that of accident and emergency departments. They see patients and treat them, but then cannot move them to other parts of the hospital because of a lack of capacity due to under-bedding or delayed discharges.

What we see in accident and emergency departments is a fiddling of the figures and delays in starting and premature stopping of the clock when it comes to the time between decision to admit and finding a bed. Because 75 per cent. of people have to be seen within four hours, minor cases are seen quickly while the more complex ones are seen later. That is a terrible distortion of clinical priorities. The hon. Member for Meriden spoke of the Government's inability to specify how many accident and emergency nurses there are. That was a case of adverb substitution—those figures are not "not collected centrally", they are "not collected deliberately". We now see noun substitution as well. Such data can only be provided at disproportionate embarrassment to the politicians, not "disproportionate cost". Changes might have to happen, but I advise the Government to sort out the capacity problems in the larger hospitals before they start closing the smaller ones.

10.40 am

Mr. Oliver Heald (North-East Hertfordshire): I start by echoing the point made by a number of hon. Members—including my hon. Friend the Member for Meriden (Mrs. Spelman) whom I congratulate on having secured the debate—that we should thank the staff in the accident and emergency departments of hospitals, particularly Barnet, who did such a wonderful job following the Potters Bar crash.

In opening the debate, my hon. Friend the Member for Meriden pointed out that the accident and emergency department in Solihull hospital had been downgraded by stealth through the instruction to ambulance crews to take patients to another hospital and by the removal, without notice, of a surgeon. The effect, over time, was to damage the ability of Solihull to deliver accident and emergency services. My hon. Friend the Member for Canterbury (Mr. Brazier) intervened and said that the same thing was happening to the Kent and Canterbury hospital: patients were being diverted away from it, against their wishes, by ambulance.

Mr. Brazier : The loss of 90 beds due to the closure of the satellite geriatric hospital at Nunnery Fields resulted in queues in our accident and emergency unit that made the national press again and again. The vicious circle described by my hon. Friend the Member for Solihull (Mr. Taylor) is happening. When they are told that there is no capacity, the morale of staff, particularly nursing staff, is affected and they become overloaded. The rotten plan put forward by the local health authority is then fulfilled.

Mr. Heald : My hon. Friend reflects the sort of comments that were made in the report on east Kent by

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the Commission for Health Improvement, which quoted one member of staff who did not know how long patients had been in his accident and emergency department, or what day it was, because of the sheer stress of numbers and the chaos in the department. The hon. Member for Oxford, West and Abingdon (Dr. Harris) said that the same was happening in west Cornwall. My hon. Friend the Member for Gosport (Mr. Viggers) then told us about the Royal Hospital Haslar, a famous defence hospital, which had also been downgraded. He explained that the old thinking that the large accident and emergency department is best had led to the change in his local hospital, and pointed out some of the problems caused by that thinking—beds blocked and modern methods ignored.

The hon. Member for Birmingham, Hall Green (Mr. McCabe) shared the concerns about Solihull hospital and agreed that people want good local services. The hon. Member for Wyre Forest (Dr. Taylor) told us that his hospital—as we know— had seen services downgraded, and he spoke of the latest thinking and of the County Durham report. My hon. Friend the Member for Westbury (Dr. Murrison) paid tribute to the work of community health councils in standing up for patients.

What is the Government's policy on rationalisation of accident and emergency departments? It cannot be coincidence that across the country—we have heard about many constituencies today, and many others are relevant—A&E departments and the supporting specialties seem to be in the process of reconfiguration by stealth. The Government document entitled "Reforming Emergency Care—Practical Steps" refers to access to emergency care being simplified and the extension of streaming of patients. However, it does not mention closing down A&E departments and developing minor-injuries units instead, or merging medium-sized units, but that is what is happening.

The argument for such measures, locally and in medical circles, is that rationalisation improves standards. Hospitals in which more than 50,000 patients use the A&E will apparently tend to have a full, 24-hour supporting service. It is said that they are more cost-effective, their doctor training is better and rostering and the quality of outcomes can be improved.

Do the Government want the rationalisation that is taking place? What guidance have they given on the subject? How has it been disseminated? What is the evidence for it?

Ms Julia Drown (South Swindon): Everything that the hon. Gentleman says rings true with what has happened over many years, rather than in only the past five years. He referred to the hon. Member for Gosport (Mr. Viggers) and the difficulties with the defence medical services establishment. The Princess Alexandra military hospital at Wroughton closed in my constituency under the Conservative Government, despite huge passion and support for it. The same pressure that the hon. Member for Gosport is bringing to bear was exerted on the Conservatives when they were in control.

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Can the hon. Member for North-East Hertfordshire (Mr. Heald) offer the Government any lessons that he may have learned from that time, or suggest any changes in policy that he may wish that there had been? The issues have been the same for many years.

Mr. Heald : The Government are in the position to conduct all the research in the world and tell us what the evidence is. The hon. Lady is right to say that A&E departments have been closed before, but the process seems to be gathering pace. Even in my county, Hertfordshire, a consultation exercise on reconfiguration is taking place, and there is rightly much local unhappiness at the thought that hospitals that are much at the heart of people's security—how people feel about what would happen if they were ill—might be in danger of closing or losing their A&E departments.

Is there any evidence of improved outcomes following the closure or mergers of A&E departments? If so, will the Minister publish it so that we can all consider it? It is often said that such measures are cost-effective. What evidence suggests that there is a release of resources as a result of them? If there is such evidence, will she publish it so that we can have an informed debate on the issue?

Is the Minister taken by the accounts that we have heard today of new thinking? The hon. Member for Wyre Forest described the experience in Durham, and my hon. Friend the Member for Gosport gave an example about combining diagnostic and treatment services with a form of accident and emergency in his local hospital. What is the Government's policy? It would be wrong for them simply to shuffle the blame on to local health managers, and say, "Oh well, they are just doing what seems right locally." There must be a plan for the whole country, or at least a network provided by the A&E departments. If so, the Government must have a policy on it.

The state of accident and emergency departments has declined rapidly under this Government. When he spoke to the National Association of Health Authorities and Trusts in 1996, the Prime Minister said that we would see an end to trolley waits and the causes of trolley waits. Since then, however, the number of patients seen within an hour has declined from 75 per cent. to 50 per cent., and the number admitted within four hours has fallen from 90 per cent. to 75 per cent.

The Audit Commission report described a host of organisational and managerial problems; and we have also heard evidence from nurses, including from the senior nurse who addressed the recent Royal College of Nursing conference. He spoke of grieving relatives being kept away from untended corpses that had been

He also spoke of people waiting for hour upon hour, and about the recent protest at Liverpool, where people had been waiting for 40 hours. What does the Minister say about the appalling decline in emergency services?

10.51 am

The Parliamentary Under-Secretary of State for Health (Ms Hazel Blears) : First, I join others in paying tribute to all the emergency services, which responded magnificently to last week's rail crash. That is the case in every major emergency. I am sure that the hon. Member for Meriden (Mrs. Spelman) knows that if such a terrible

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event were to happen in her community, the emergency services would again respond magnificently, and I confirm that there is a major contingency plan for her area. The hon. Lady put forward the possibility of an incident in her area, and explained that the growth of shopping and tourism mean that a large number of people are there during the day. I can give her the strong reassurance that the emergency services are prepared and able to cope with matters excellently for local people.

The debate has been passionate on both sides. That delights me, because it shows how much local services, particularly emergency services, are valued. The fact that so many hon. Members attended today, contributed to the debate and made their views clear gladdens my heart. I was quite surprised, however, to be criticised by the hon. Member for Meriden for humility; our document "Reforming Emergency Care: First Steps to a New Approach" was a deliberate attempt to deal with a complex matter. We do not have a magic wand, and the position cannot be resolved overnight.

As many hon. Members said, the pressures on accident and emergency departments have existed for many years—and many of them suffered also under previous Governments. However, the debate should not be about accident and emergency departments only, but about the whole system of care. Many hon. Members highlighted the fact that it is also about primary care, access to general practitioners, social services, the overall capacity of hospitals and the effective and proper discharge of their duty—and the fact that if one part of the service is not working properly the effects are inevitably felt most acutely in A&E departments. Hon. Members have made it clear that the problems in overstretched A&E departments are sometimes the result of pressures that are not under their control but which they are unfortunately left to deal with and involve a complex set of interlinked and interrelated matters.

The contribution of the hon. Member for Meriden was in stark contrast to the more thoughtful speech by the hon. Member for Gosport (Mr. Viggers). I had the opportunity, with the hon. Gentleman, of discussing with local councillors and members of the local community their real concerns. We talked about the way in which emergency services are changing, and whether it will be possible to provide more services closer to home. However, we recognised that they will not always include full a trauma service with a complete range of critical care back-up, because it is not realistic that it should be available within 10 minutes for everyone in the country. I hope that Opposition Members will be prepared to engage in a realistic and mature dialogue with their communities about that. Yes; we want to provide as many services as we can as close as possible to people's homes, but that aim will always be tempered by issues of clinical safety, organisation, resources and training, and by the need to ensure that the royal colleges can accredit such circumstances. The picture is complex; it is not simply a matter of having a full range of accident and emergency services within 10 minutes of where every single person in the country lives.

Mr. John Taylor : Respectfully, I need no lectures on how to keep in touch with my community, having been born there and having had a continuous mandate from

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the people of Solihull for 31 years. I should, however, draw the Minister's attention to the perversity of justifying the downgrading of accident and emergency provisions on the grounds of lack of throughput, when throughput has been intentionally diminished by instructions to ambulance crews.

Ms Blears : The hon. Gentleman knows that, as my hon. Friend the Member for Birmingham, Hall Green (Mr. McCabe) said, a variety of services has been available at Solihull and Birmingham Heartlands over the years. There have been different protocol referrals, according to the needs of the patients who were being transported and referred. That links with the issue raised by the hon. Member for Wyre Forest (Dr. Taylor). If we are to explore different kinds of accident and emergency treatment and provision, it is crucial that we get the protocols right, so that the right patients go to the right place for the right treatment by the right members of staff. That will ensure that people do not end up being processed through one place before being transferred somewhere else, which would create difficult delays for patients.

Several hon. Members rose—

Ms Blears : I want to respond to the other points that hon. Members have raised, and I have four minutes to do so, so I want to press on.

My hon. Friend the Member for Birmingham, Hall Green made an important point about ensuring that there is a local dimension to such issues. A wider range of facilities is beginning to appear. There are not only accident and emergency departments, but nurse-led minor injury care centres and one-stop primary care centres, and walk-in centres are being developed. All those are about providing different elements of emergency care. We must challenge ourselves to think more imaginatively and more creatively about the provision of emergency care. We should think not only about the A&E department, but about the whole system, and it is crucial to ensure that it is interlinked.

Mr. Peter Lilley (Hitchin and Harpenden): Will the Minister respond to the point made by my hon. Friend the Member for Meriden (Mrs. Spelman) about providing information? When provision at St. Albans was merged with that at Hemel Hempstead—against strong opposition from locals and myself—we were told that the move was necessary to improve health outcomes. Since then, evidence of such improvements has not been forthcoming. We have asked that Ministers carry out a nationwide study of mergers to clarify whether they have produced better health outcomes, before further mergers, including the possible closure of half or three quarters of the accident and emergency units in Hertfordshire, are carried forward. Will the Minister promise to provide that information, and if not, why not?

Ms Blears : What is important is that we are talking about what local people can decide to do for themselves. The hon. Member for Meriden will know that there were about eight options for various configurations of emergency services in her area. No decision has been taken on which options will go out for public

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consultation, but it is crucial that the detailed weighing-up of what is best for the local community and what combination of services will properly provide for local people is done at the local level, with the primary care trusts in the lead. It is crucial that we bring together clinicians, local patients and all those who make up the neighbourhood. It is not simply a case of the Government coming up with a national template—a top-down solution—that will act as a blueprint for everyone. Local communities must be involved.

Mr. Heald : On a point of order, Mr. Taylor. Is it in order for the Minister to misrepresent the words of my right hon. Friend the Member for Hitchin and Harpenden (Mr. Lilley)? He asked whether she would publish the evidence on whether mergers and reconfigurations make a difference.

David Taylor (in the Chair): That is a matter for debate, not a point of order.

Ms Blears : Thank you, Mr. Taylor. In the minute that I have left, I should commend the emergency care strategy to hon. Members. It is complex, and refers to streaming, extra investment and reform. It is key.

I challenge Opposition Members to be more creative and more imaginative in their approach to the issue, and I urge them to read the strategy. It has the full support of the British Association for Accident and Emergency Medicine, which looks forward to implementing it with the Government. The strategy was formulated with local people, so local communities have had a chance to ensure that it can work.

Opposition Members should not take such a simplistic view of emergency care. It is a complex issue and all the services are interrelated, but the arrangements can work. As usual, Opposition Members are being harbingers of doom and gloom, and feel that nothing can ever improve. I can promise that things will improve, however, provided that the strategy is properly implemented.

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