Sarah Montague: There have never been so many people trying to use Accident and Emergency services in this country. Last year the number reached 21.7 million. That’s up 50 per cent in a decade. The Conservative MP Chris Skidmore who’s a member of the Commons Health Select Committee wrote an article in the Daily Mail yesterday suggesting one of the reasons for the rise might be immigration. And he’s proposed restricting health services to immigrants. He joins us on the line now as does the Chair of the Royal College of GPs Clare Gerada. Good morning to you both.

Chris Skidmore: Good morning.

Clare Gerada: Good morning.

Sarah Montague: Now Chris Skidmore we heard earlier from the chief economist of the Kings Fund that actually the numbers haven’t increased much in the last few years. The jump would appear to be earlier?

Chris Skidmore: That’s right. Between 1987 and 2003 admissions to A&E were fairly stable, around 14 million. It was about 2004 that suddenly it spikes to 16.5 million and we’ve seen it rise from there on in.

Sarah Montague: Now the Health Secretary has suggested that it was down to, I think his words were the ‘disastrous renegotiation’ of the GPs contract which has left people going to A&E instead. But you’re suggesting something else?

Chris Skidmore: Yes. I think we do need to look at the changing demographics of this country. Not only above all an aging population, you know, 70% of all admissions are people over 75, but that the population over the past decade rose to 56.1 million, the largest rise in the past 200 years. So I think we do need to understand what has happened. What are the long term trends for this reason why the admissions to A&E have increased?

Sarah Montague: And you’re suggesting is it’s down to, it’s as a result of immigration - it’s basically immigrants who are putting an undue, unbearable burden on the NHS?

Chris Skidmore: That may be part of the problem. I mean, above all, the two biggest drivers I think for A&E are an aging population and people turning up at A&E unnecessarily sometimes. But when you look at the evidence, John Heyworth, President of the College of Emergency Medicine has said that migrants routinely visit A&E instead of actually going to their GP. And when you look at UK Border Agency studies of about 700 migrants only half were ever registered with a GP. So what you’re finding is that immigrants are not registering with GPs and going directly to A&E which may account for part of the rise in admissions.

Sarah Montague: Clare Gerada is it a problem that you recognise, of the use by immigrants of health services and of A&E in particular?

Clare Gerada: Well, your piece is so riddled with inaccuracies, I don’t really know where to start. We have to actually nail some facts. There has not been a significant rise in attendances in the Emergency Department over the last decade. If anything in London it’s flat-lined. The blip we saw in 2004 was due to coding changes, nothing to do with the GP contract. The second issue, immigrants…

Sarah Montague: So hang on, actually, just before you go on any further - more people are using A&E than ever before?

Clare Gerada: The figures don’t show that. It’s increased by about 1.7% per year over the past decade and that’s less than the rise in the population. What we have seen, and I’ll accept we’ve seen, is a very recent blip. Since about August last year, certainly between January and March this year, something has happened. Maybe it the long winter, the long cold winter, we’ve certainly had a nasty flu virus. So we have to get these facts right. The second fact we have to get right is that the vast majority of out of hours services at this moment in time are delivered by GPs. But I don’t want to be defensive. The two parts of the NHS, the floodgates of the NHS which is the Emergency Department and General Practice are heaving under the workload.

The worry about this Kings Fund report actually is that it’s showing that with a relatively mild winter, it was long but it was relatively mild, the Emergency Department has seen this enormous increase, recently, as has General Practice. With respect to immigrants you are much more likely to have an immigrant caring for you than sitting up in front of the Emergency Department. I will accept there are certain migrants especially those from Eastern Europe who don’t have a tradition of General Practice who will go to the Emergency Department rather than to General Practice, and we need to address that. But it’s certainly not responsible for the massive increase we’ve seen in recent months and it’s certainly not responsible for the 1.7% increase that we’ve seen over the last decade.

Sarah Montague: Could you just deal with that point first of all Chris Skidmore, that the problem as you present just isn’t there?

Chris Skidmore: Well I’ve taken my evidence from the Kings Fund, so in terms of the statistics Clare may be right but in terms of, you know, the numbers, I’ve gone on an independent health think tank. I do think in the longer term trends, you know, the anecdotal evidence - I didn’t want to go on anecdotal evidence but people…

Sarah Montague: Surely, you’re talking about the same numbers here and you say you are using the Kings Fund statistics, surely that is exactly the same thing? The numbers, the statistics are the same…?

Chris Skidmore: Well that’s right, and you’ve seen the rise…

Sarah Montague: And Clare Gerada’s point is that is as a result of the change in the way - as I understand it Clare Gerada - a change in the way the statistics are collected, rather than an actual jump in the numbers?  

Clare Gerada: Yes and it’s also, can I be clear, that in 2004 we improved access to urgent care through the system of setting up urgent care centres and minor injury units. All of those were coded as Emergency Department attendances. If you actually…

Sarah Montague: You mean the numbers were equivalent before; they just weren’t coded in that way so they weren’t counted in the figures?

Clare Gerada: They weren’t coded, and we also introduced - rightly so - improved access to urgent care.

Sarah Montague: Right. There’s no point us going down the argument in lots of detail but Chris Skidmore - that question - do you accept that if there isn’t a problem you wouldn’t need to restrict it in this way?

Chris Skidmore: No I don’t. I think in the longer term what I’m interested in looking at is the fact that we are going to have a massive rise in the aging population, a massive rise in the number of patients presenting themselves with chronic conditions. So the IMF and the IFS both suggested that the NHS…

Sarah Montague: And your solution - can we get to your solution - your solution is what, that you have a system like the Green Card in the United States?

Chris Skidmore: Yes, what I believe we should be introducing is a system by which those people who enter the country looking for work… now you know, no-one’s got any problem with migrants working hard, paying their share of tax, getting access to public services. The problem we have is that people have this perception that migration is a bad thing, that people are using public services. I think that if we had a system where migrants were able to come to this country, have medical insurance to start with and maybe after 5 year of paying tax were then able to access NHS services for free, then we’d have a system where people would understand that migration is a good thing, people have paid their tax and are not abusing the NHS. So what I’d like to see is actually a system where - going back to the contributory principle, people putting in in order to get out.

Clare Gerada: Well let’s talk not about abuse and let’s talk about facts. Migrants - immigrants - tend to be much younger, they tend to be very low users of national health services, I grant they may well use maternity services more. The second thing is, the NHS is not designed to have a two-tier system, one where you pay, you stand in the queue with your credit card, and the other where you go through as we all do now.

Sarah Montague: But maybe it should be re-designed?

Clare Gerada: Well then we fundamentally change the very basis of our National Health Service, which is free at the point of use. And this isn’t a new issue. Bevan when he set up the NHS dealt with it and he actually talked about generosity and convenience coming together. The numbers are probably very very small of those not entitled to health care abusing the system and I think we need to make sure that we deal with that. But at the moment we have laws that allow people coming in as students, as those who are working and coming for a long stay, free access to our national health service.

Sarah Montague: Clare Gerada, Chris Skidmore, thank you.