HC Deb 03 April 1990 vol 170 cc1174-80

Motion made, and Question proposed, That this House do now adjourn.—[Mr. Tony Durant.]

11.47 pm
Mr. Doug Hoyle (Warrington, North)

I should like to thank the Parliamentary Under-Secretary of State who has stayed to reply to this Adjournment debate, because he has had a wearying evening up to now and a long day; but I assure him that it is a matter of great concern to the people of Warrington and Cheshire because it concerns the out-patient services provided in Warrington and Cheshire.

During the ambulance dispute, the managers ordered cuts in non-emergency out-patient services. As a result, the number of vehicles available for out-patient services in Warrington was reduced from 10 to three. I must refute right away the statement made on behalf of health service managers by Hugh Lamont of the Merseyside regional health authority, who alleged that these cuts were made because ambulance crews refused to provide out-patient services. I read from a press release of the Warrington health authority, which is signed by Mike Shannon, the unit general manager of the district general hospital, about the industrial action in the ambulance service: In order to maintain the emergency ambulance service it is now necessary to reduce the non-emergency workload ambulance staff. As from Tuesday 10th October 1989 there will be no outpatient transport available to walking patients. The inconvenience that this will cause is very much regretted, but the reduction in this service is necessary to sustain the emergency service … The geriatric day hospital of the general hospital and the elderly severely mentally day patient unit of Winwick hospital are not affected. That action was taken by the management. Indeed, the press release recognised the inconvenience that the reduction would cause.

It is therefore surprising that, far from beginning to increase provision, the management are trying to maintain the position that applied in Cheshire generally and in Warrington in particular. They have reduced the number of vehicles for out-patient services from 10 to three, despite the discomfort that that would cause, and which was recognised by Mr. Shannon in the press release.

Evidence of that is shown in a memo from Mr. M. J. Lloyd, divisional commander control, Cheshire ambulance service. He said: At a meeting with the D.H.A. representatives of all Cheshire districts today, the following level of P.T.S. provision was insisted on. It will therefore be actioned from Monday 12 March 1990—no increase in the level of provision that has been operative during the national dispute. I have already referred to the severe cuts in Warrington and in Cheshire generally. Mr. Lloyd also said: In operation requests for transport must always be met with a negative response, it is then up to the person requesting to medically justify the request. Any problems regarding this should result in the person requesting being directed to the relevant unit general manager. I cite that document as evidence that the Cheshire ambulance service and, indeed, district health authorities throughout Cheshire, are trying to keep provision at the skeleton level that applied during the national dispute. That has already caused many protests from organisations in Warrington and Cheshire generally.

Those cuts were made without consultation with anyone, and certainly without observing the statutory duty to consult the community health councils. I wish to quote a letter sent on 23 March to Mr. Rae, the district general manager of Warrington health authority, from Mrs. Roylance of Warrington community health council. She said: The committee is extremely concerned that the decisions referred to … have been implemented without consultation. She goes on to say: The CHC questions the basis on which the instructions were issued: (i) the reduction in the level of service represents `a significant variation in the provision of service' on which the CHC has a statutory right to be consulted. That consultation did not take place. Indeed, in a final paragraph, Mrs. Roylance says: The Chairman and members of the Council are deeply concerned that the CHC's statutory right to be consulted has been ignored and they request the resumption, without delay, of the level of ambulance service available in Warrington prior to the national dispute, pending the outcome of formal consultation.

It is quite evident that this has upset all the members of the community health council. They make the point that they were not consulted at all in relation to this.

What has happened in Warrington and in Cheshire in relation to out-patient provision—or the lack of it—is, I suggest, a breach of the Government guideline in health circular HC(78)45, which says: Ambulance services are required to provide or arrange the provision of suitable transport, free of charge, normally to the nearest hospital or treatment centre with hospital based facilities, where the necessary treatment can be obtained, to NHS convalescent homes, dentists' surgeries or Artificial Limb Appliance and Assessment Centres for any patient (emergency or non-emergency) who is considered by a doctor, dentist or midwife to be medically unfit to travel by any other means. The words "by a doctor, dentist or midwife" are very important in the context of the rest of what I have to say in relation to this matter.

I now have to quote from a press release, again issued by Mr. Mike Shannon, who, I remind the Minister, is not a clinical practitioner but the unit general manager of Warrington health authority. He says—this was issued on 28 March— As we know, the recent industrial dispute within the ambulance service has now ended, and great efforts are now being made to reinstate an appropriate service as quickly as possible. This is being done, but strictly in accordance with the long-established rules within the Health Service that ambulances are not white taxis"— whatever Mr. Shannon means by white taxis; I presume he means that a taxi service was being provided, rather than an ambulance service— but can be authorised only on medical grounds. If Mr. Shannon, in referring to a white taxi service, is claiming that the service has been abused and ambulances have been ordered on other than medical grounds, he gives no examples.

The unit general manager has no right to question in this way the clinical judgment of doctors, dentists and midwives. Now, of course, ambulances will be allowed not on medical grounds but on the whim of the unit general manager. In his reply to Mrs. Roylance he claims that these services are strictly in accordance with NHS rules, but they are not. He goes on to say: Ambulance services are authorised by clinical staff. So far, so good, but then he says: If there is a dispute between the requester and the ambulance staff, I am called upon to arbitrate. The unit general manager may have many worthy and endearing qualities, but why should he be called upon to arbitrate when a clinical judgment has been made? He is saying, in effect, "I shall have the final say as to whether a service shall be provided."

The result of this arbitrary action is that those who are least able to speak up for themselves are the most affected, in Warrington and the rest of Cheshire. I am of course referring to the sick, elderly, infirm and disabled. It is having a devastating effect on those people.

I do not have time to cite the many examples that I have. So I will give two, as reported in the Warrington Guardian of 30 March. In the first case, that newspaper wrote: Hospital staff said … that out-patient services have … been minimised to stretcher cases only. One out-patient, who has just had his right leg amputated, was told he is not eligible for transport and must continue making his own way to hospital. The 71-year-old ex-serviceman, secretary of Culcheth Royal British Legion, told the Guardian: 'I have just been fitted with an artificial leg and have to visit a physiotherapist every week to learn how to use it. I also make regular visits to the Artificial Limb and Appliance Centre in Liverpool and am continually having to depend on friends. This is a very desperate situation.'". Clearly, such a man is covered by the guidelines and should have been provided with transport.

In the second case, the paper wrote: Another woman aged 72 was refused an ambulance to have an artificial leg fitted in Liverpool. She had no friends or relatives to help, and was forced to cancel the appointment and manage without. Nobody—least of all the Minister, knowing him as I do—would try to justify that state of affairs or what is happening to the out-patient vehicle service in Cheshire and particularly in Warrington. How ill does a person have to be to qualify for an out-patient vehicle in the area? Why are those concerned not abiding by the guidelines, particularly when, it seems, the decision no longer rests with the members of the clinical profession but with accountants and faceless bureaucrats, such as the unit general manager? They should be obliged to live up to the guidelines laid down by the Department.

We must not forget the effect that all this will have on jobs. The non-emergency ambulance staff, because of the reduced number of vehicles in Cheshire, are not Fully deployed, even if they are fully paid. If those members of staff are not being deployed, redundancies are bound to result. Indeed, as many as 60 drivers in Cheshire could be made redundant, and nine of them will be in Warrington.

During the ambulance dispute, half the non-qualified ambulance staff were put on temporary contracts. Their services will be dispensed with as soon as the management finds it convenient to take that step. Penny-pinching of this kind must not take place at the expense of the sick and those in need. The cuts should cease immediately, and I hope the Minister will announce that from tonight, full out-patient transport services will be restored.

12.4 am

The Parliamentary Under-Secretary of State for Health (Mr. Roger Freeman)

I am grateful to the hon. Member for Warrington, North (Mr. Hoyle) for the kind remarks which he made at the outset of this brief debate. The hon. Gentleman thanked me for staying. I am always pleased to reply to debates that he initiates, but the hon. Gentleman is the only person present who has any choice in the matter. You, Mr. Deputy Speaker, and the only other person present in the Chamber apart from myself—my hon. Friend the Member for Reading, West (Mr. Durant) —have no choice in the matter. Nevertheless, I am grateful for the hon. Gentleman's remarks.

The hon. Member for Warrington, North concentrated on out-patient ambulance services and upon the consequences for the patient of the changes that I shall describe in a moment, rather than the consequences upon the unions. He was fair to do that, and I shall therefore concentrate on the consequences for patients.

Since 1982, the Chester health authority has managed a single ambulance service for all five district health authorities in Cheshire—Chester, Crewe, Halton, Macclesfield and Warrington. It has run that service efficiently, and has introduced diesel vehicles, paramedic training and cardiac care training. A lot more needs to be done, but the authority is to be congratulated on the start that it has made.

As with all other ambulance services throughout the country, there are two fairly distinct aspects to the service. The first and most important is the need to respond promptly to accidents and emergencies—or 999 calls—to meet doctors' requests for urgent admissions and to move patients who need to be transferred from one hospital to another. These can, quite literally, be a matter of life and death, and it is entirely right that the utmost priority should be given to that side of the service. Recent events have underlined the importance that the public attach to the accident and emergency service. The other aspect is the routine transportation of outpatients to and from hospital or treatment centres. That is clearly the service which the hon. Member is most concerned about.

When we talk of routine cases, we have to distinguish between patients who have a medical dependency, such as oxygen therapy or who may need to be lifted in and out of their homes—those are clinically necessary services which are provided by the Cheshire ambulance service—and those patients who simply need a transport service to and from hospital. I say "simply", but of course that transport service is important, particularly for those people who need some form of public transport because they do not possess a car, or because it is to far to walk to and from the hospital.

In the examples which I have cited, where there is a clear clinical necessity, the service is clearly needed and will continue to be provided. However, the social need for transport is not a function of the ambulance service.

The hon. Gentleman has pressed me to define what is meant by clinically necessary services in his health authority and, most importantly, who defines what those services should be.

Before the ambulance dispute, I am told, the Cheshire service had 37 ambulances available as emergency ambulances but very often only between 12 and 14 were available, as quite a number—clearly the majority—were being used for non-accident and non-emergency work. Clearly that was unsatisfactory, because the accident and emergency service can, and I understand in some cases did, suffer.

Now the fleet of ambulances in Cheshire has been modernised. Some 20 ambulances are dedicated to accident and emergency work and there are some 22 other vehicles for non-accident and non-emergency work. I am told that those mainly comprise 10 to 12-seater vehicles. The numbers will grow marginally in the future to some 22 ambulances dedicated to emergency work and some 24 for non-emergency work.

A new system has been introduced for financing the ambulance service in Cheshire from 1 April this year. The proposals were under consideration before the dispute began but are only now being introduced.

The amount retained at the Chester headquarters for the accident and emergency service proper is some £4 million for 1990–91, and approximately £1.2 million has been allocated to the five districts. They will use that sum to purchase non-accident and emergency services either centrally from the Cheshire ambulance service—I have indicated the vehicles that could be available—or locally. The key requirement still is that the services provided must be clinically necessary.

Locally, there will be patient transport managers in the districts, to assess the needs for non-accident and emergency work—always concentrating on the clinical need for such services.

The hon. Gentleman asked the perfectly fair question: to what extent is authority delegated to those managers for making clinical judgments? I do not expect them to make clinical judgments. That is not their function. The responsibility for making the decision as to whether or not a patient is, for clinical or medical reasons, in need of transport rests with the medical staff, not the managers—who are there to manage the service and to match resources against clinical need.

It may help if I explain the reasoning behind the proposals. Until recently, during the day there have been about 37 ambulances theoretically available as a maximum for accident and emergency duties, but only one third of those could really be called on if needed. The other two thirds have been engaged on routine duties such as planned admissions to hospital or carrying out-patients to and from treatment centres. Not only has that reduced the number of vehicles available for emergencies, but it has been wasteful of resources to deploy fully trained and equipped crews on duties that could easily be carried out by personnel with less training, in simpler vehicles.

While Cheshire has managed overall to meet the minimum times laid down nationally for responding to an accident or emergency call, the position at individual stations has often been dangerously near, or actually below, the mark. This has put a considerable strain on the service. At night, at weekends, and during the "quiet hours", the level of emergency cover has stood at only 17 ambulances. Taking into account the geographical spread of Cheshire and the network of motorways that intersperses the county, that is very sparse cover.

Demand has sometimes meant that even ambulances reserved for accident and emergency duties have been called upon to deal with planned journeys involving patients discharged from, or being admitted to, hospital. It is for these reasons that the working party studying the needs of the Cheshire ambulance service has recommended a two-tier service. That does not mean a first and second-class service. The proposal is for a distinct accident and emergency service with the very latest equipment and with staff trained to the highest level, able to perform a range of life-saving techniques—and, it must be said, with more dedicated vehicles.

The non-emergency ambulance service will continue to transport patients with a medical need as determined by a clinician. That service, as organised by Chester for the county of Cheshire, will be available to the districts. They will have freedom either to purchase services from Chester or to make their own local decisions.

There may be patients who can make their own way to and from hospital but who find difficulty meeting the cost of travel. They can apply for help with these costs and should ask the hospital about this. The Department of health leaflet H11, "NHS Hospital Travel Costs", explains who can claim help with fares incurred travelling to and from hospital and how the scheme works. There is also a Cheshire dial-a-ride service for registered disabled.

That is our mechanism for providing help in a social context for those who cannot afford the full costs of travelling to or from hospital.

Mr. Hoyle

The dial-a-ride service does not provide that, nor was it set up to do so. Its purpose is to provide vehicles, not for travel to hospital, but for disabled and other people who need to go shopping and so on. There cannot be help from that service, because it is already stretched to the limit.

Mr. Freeman

I am grateful to the hon. Gentleman; I stand corrected. The record will show that it is a service available within the community and not to and from hospital. I am not familiar with the service, but doubtless next time I am in Cheshire I shall make detailed inquiries about it.

I should make it clear that geriatric day care attendances, with which there were, I understand, some problems during the recent dispute, will be given priority, as will other cases which in the light of individual circumstances merit special attention. I am talking now about the non-accident and emergency services. The intention is to use the available resources to best effect and to make sure that those who really need the service obtain it—that is, those with a clinical need—as promptly as possible.

The working party has also recommended that ambulance stations provide more flexible and appropriate cover throughout the country. It has recommended that there should be a redistribution of resources to provide 22 emergency ambulances during the day and 20 at night. This will improve cover in the Crewe, Ellsmere Port, Malpas and Warrington areas. These recommendations are aimed at strengthening the accident and emergency service and providing overall a service more tailored to the needs of the people who use it.

Mr. Hoyle

There are two points I should like the Minister to explain. Why was there no consultation with anyone, and particularly with the community health council? I am willing to give the Minister a copy of the document. How can he say all these things when Mr. Lloyd, divisional commander, control, says plainly that there has been no increase in the level of provision operative during the national dispute?

Mr. Freeman

I do not know to which document the hon Gentleman is referring. I look forward to receiving a copy from him. I shall certainly look into the point about consultation procedure. I shall also send copies of the Official Report to region and district for additional comment.

As I understand it, this is a reorganised service which concentrates the resources on accident and emergency and which does not diminish the proper service which should be provided for those who have a clinical need for transportation. It means, perhaps, that those with no clinical need who were using the service will no longer be able to do so. I believe that it concentrates resources where they are most needed in the hon. Gentleman's constituency. I think that is best, not only for his constituents but for the Health Service as a whole.

Question put and agreed to.

Adjourned accordingly at seventeen minutes past Twelve o'clock midnight.