HC Deb 01 April 1993 vol 222 cc669-85 3.39 am
Mr. Nigel Spearing (Newham, South)

It is with no pleasure that I introduce this debate about the relationship of Ministers and their accountability to the London ambulance service. The debate may well be important because it is a classic one for bringing Ministers to account. Although the hour is either late or early, whichever one chooses, our words are being recorded.

The London ambulance service is a tragedy which has focused on failure. The failure of the service was not surprising to many of us, unfortunately, as there has been a long period of decline, disorganisation, disintegration and, indeed, maladministration of a service which was once the best in the world. Alas, we cannot say that today. The decline in standards of public service which the LAS has experienced has been entirely under a succession of Ministers or Secretaries of State of one political persuasion.

I do not want to make too much of political differences tonight, although they may emerge in any investigation which takes place. I had hoped that, in this vital public service in which there can be no disagreement about the need for its presence and efficiency, there would be no difference. If there is a difference—a difference has, unfortunately, emerged—we must draw some bigger lessons from it, but not immediately.

We must draw some lessons from the vital matter of public accountability, especially when such a service is funded by the public and is run in any way other than as a visible public service. The emergency service at least is run in such a way. The service is run in such a way that its efficiency can be measured easily, yet there has been a most tremendous, tragic and, indeed, fatal failure.

Earlier, I said that the failure is not surprising to some of us. One of the reasons why I am both sorry and glad to have this debate is that I have followed the matter closely for more than six years. There have been seven debates on this matter since 1986, excluding all the debates that took place during the tragic dispute.

The first debate I remember was on 15 May 1986. It was raised by a Conservative Member—I think it was the hon. Member for Ravensbourne (Sir J. Hunt). I had Adjournment debates, to which I shall refer in a moment, on 31 October 1986 and 14 May 1987. There were Consolidated Fund Bill debates on 8 December 1987 and 20 December 1989. I presented a petition on 7 December 1989. There was an Adjournment debate on 18 April 1991 and a Public Accounts Committee debate on 17 October 1991 before I asked the Secretary of State for Health a private notice question on 28 October 1992, following the tragic collapse of the system on 26 October 1992.

In passing, I should ask how many debates have taken place about the London fire service. I do not recall any such debate. I wonder how many questions there have been about the London fire service. There have been few such questions.

We must ask ourselves why there is a difference between two services which are not dissimilar. One deals with property and the other deals with life. One would have thought that life and human suffering, distress and grief might have the priority of the two.

The London ambulance service has been a matter not only for debate. Hon. Members, including those who support the Administration, have sent letter after letter to Ministers. They have asked parliamentary question after parliamentary question. As I have just described, there has been debate after debate. However, as far as I can see from the evidence—the Minister may say something to the contrary—Ministers have not taken any notice. Indeed, the Minister who is present tonight, the Under-Secretary of State for Health, the hon. Member for Bolton, West (Mr. Sackville), has not taken any notice, as I shall proceed to demonstrate.

I take Parliament seriously because ordinary people who pay taxes—however taxes are levied and whether they are fair or unfair—have no other means than Parliament of ensuring that the money which they collectively contribute is administered properly. This is the last place. It is either this or bullets.

Ministers not taking notice also reveals something else. Some time ago I read books about politics, perhaps idealistic ones, which said something like, "A wise Minister uses parliamentary questions as a searchlight to throw light on the nooks and crannies of every aspect of his or her Department." Unfortunately, the searchlight of parliamentary debate and questions in the past six years and even recently has been blanked out by Ministers.

Was it deliberately or through inefficiency? That question must be answered. I will try to answer it. If it is either cause, some action must be taken. That is why London Members signed an early-day motion about ministerial resignations. That is serious and I wish to say why, alas, resignations are necessary.

After that introduction, I intended my speech to have three parts. The first was the events that took place in the tragic run-up to the collapse of October 1992 and the events that some of us almost foresaw. The second was what happened after the collapse, and the lack of action by both the Secretary of State and the Minister. I do not know who was responsible. I suppose that the Secretary of State is responsible in the end. If the Minister did not tell her what was going on, he is responsible. So one of them is responsible.

I know that the Secretary of State and the Minister inherited a situation, but Ministers who inherit a situation have the opportunity and the duty to find out what it is and, if it is unsatisfactory, to do something about it. But, as I shall demonstrate in a moment, both the Ministers who are in office at present did not do so. Indeed, I believe that, although they have taken some action, it was not what is required.

The third matter is the action that the Secretary of State and the Minister did or did not take, subsequent to the inquiry report which was published a few weeks ago. This is the first opportunity that the House has had to debate that report. An unexpected fourth part of my speech is the events of yesterday. A ministerial statement has been made and letters have been sent from the Secretary of State to the chairman of the South West Thames regional health authority, which I read about in the newspapers. I obtained the press release on application to the Library earlier today.

The Secretary of State may have sent London Members copies of the press release which have not yet arrived. Perhaps the.Post Office, which we discussed in the previous debate, is not efficient. Certainly, I had to take my own initiative to find out what the letters said. Given that we were to have a debate on the matter tonight, that is a little surprising.

Before I embark on the history of the London ambulance service, I want to say something about the staff. I regard the ambulance staff of the London ambulance service as some of the finest people I have met, but they have been denigrated and criticised. In letter after letter and statement after statement, their alleged shortcomings have been made at least part of the excuse for what is going wrong.

I am very sorry that the Minister who is here tonight—I emphasise "the Minister" in his ministerial capacity, not as a Member of the House—was party to that. I do not know who served up that sort of information. I am not going to say that everybody is a saint, but I believe that the collective guilt that has on occasion been landed in the direction of the ambulance staff has no, or very little, basis in fact; certainly not the sort of basis that the Minister, in letter after letter, and the publicity machine of the administration of the ambulance service have implied.

The number of ambulance staff who reach retirement is not very great. The number of ambulance staff who have a very long retirement is very small indeed. You and I appreciate, Madam Deputy Speaker—indeed, I hope that all hon. Members, including Ministers, appreciate—the strain experienced by those emergency staff who have to deal with a succession of human grief and tragedy, not knowing what is coming next. By the very nature of their occupation, the strain is pretty great. It is difficult watching it on television sometimes when we know that it is real; we can only imagine what it is like when one is in the middle of it.

I regard the staff of the London ambulance service as professional Samaritans, and they must be given the tools for the job. I recall that, in interpreting that parable, which one hopes is still a basis of our society, one well-known person was heard to remark that it was very good that the Samaritan had some money to pay the innkeeper. What the person who made that remark forgot was that, in giving the money to the innkeeper, the Samaritan told him to do what was necessary for the man and he, the Samaritan, would repay him. He did not put a cost cap on it. In other words, it was demand-led, and that, until recently, is what the London ambulance service was.

Let us look at what has happened. Up to the mid-1970s, the London ambulance service, was, of course, run by the Greater London council, directly accountable to a committee and to elected members, one per parliamentary constituency. So any shortcomings on any matter relating to things that were going wrong could be dealt with verbally by members, or if necessary by letter to the chairman of the committee—all in minutes, all account-able; a monthly meeting at least, and discussed if necessary at a meeting of the council.

That was changed. I will not go into the details—it may have been a mistake; it may not have been—but things began to go wrong in the mid-1980s, in particular in the summer of 1986. That was when I first became involved.

I began to get heartrending letters from people who, by definition, were sick, and many of them elderly, and who had appointments at out-patient departments. We all know how many people go in and out of hospital pretty quickly these days and have to go back for out-patient treatment. Some of them will not get well. Those appointments were being cancelled because there were no ambulances. I do not mean the stretch-out variety; I mean the ones with tailboards and skilled staff. Many of the patients had crutches, and that sort of thing, so skill was needed. I have heard from the staff that it is not just the emergency people who suffer strain, because there are people up and down stairs and in and out of houses, and people who are very sick and have to be given assistance.

I wanted to find out what went wrong, and that was the subject of my first Adjournment debate, on 31 October 1986. It was replied to by the hon. Member for Derbyshire, South (Mrs. Currie), a rather well-known personality, now on the Back Benches. I was astounded by the key sentence in that debate, which I will repeat. She said: About 10,500 fewer walking patients were being transported—a reduction of 44 per cent. I am more than happy at that development."—[Official Report, 31 October 1986; Vol. 103, c. 666.] I nearly fainted when I heard that.

I shall make no further remarks about that particular former Minister except to say that anyone who has the opportunity to use someone who made such a comment should consider whether that remark was a qualification or a disqualification for public office.

I corresponded with the Minister and discovered that the justification for that remark was a belief that there had been abuse of the patient transport service, which was complementary to the emergency service. I believe that it is now put out to tender and that, in certain areas, the London ambulance service has lost to the competition. Heaven knows what will happen to the stability of the service if it comes up for tender every year, but I mention that only in passing.

When the then Minister said there had been abuse of the service, I asked for proof, both in writing and in parliamentary questions. Proof there came none, so I put it down to personal eccentricity. Those who know the hon. Lady—of course I told her that I would be mentioning her tonight—will know what I mean. The other reason she put forward with great eloquence during the debate and subsequently was that the patient transport service needed to be cut to keep the front-line emergency service, which she praised to the skies, running properly.

I believe that the general cuts were due to the Rayner study. A paper was published by an official of the West Midlands ambulance service and that was the beginning of a reduction in resources to the London ambulance service. It was cost-budget capped.

In subsequent debates, the excuse by Ministers was that cost capping was required throughout public expenditure. The Minister would argue that the Labour Government did that, too. That is arguable. However, whatever the arguments about the level of the patient transport service, the emergency service must be demand-led within the Orcon standard, which is well known throughout the country. It is essential to provide the resources to achieve the Orcon standard, which is, by common consent, a reasonable standard of service. That was not happening. The tap was being turned down and the London ambulance service was carrying deficits year after year. I tried with difficulty to find the accounts.

Then the Government had the effrontery to apply a 3 per cent. efficiency reduction. Organisations such as Sainsbury, Tesco and Boots do that to keep the management on their toes, and the Government thought they could apply value for money to that vital service. Of course, it did not work. There were difficulties about pay and so on until the tragic dispute—I use the word "tragic" advisedly.

The Secretary of State at the time was the right hon. and learned Member for Rushcliffe (Mr. Clarke), who had started what I believe and what history will judge as a trail of destruction through the health service and the education service. Now he has been arrested—in the other sense of the word—by the police. We now have the promise of a police board for London to which I hope the current Home Secretary or any future Home Secretary will not repeatedly refer us, rather than to the Minister responsible.

In response to the White Paper "Working for Patients", published in January 1989, under the guise of the rather tenuous paragraphs 2.8 and 2.9, the South-West Thames regional health authority created the London Ambulance Board. Most people would not have a clue about who runs the ambulances in London—they might now, however, because of recent unhappy publicity. They were the responsibility of one regional health authority, which covers only a quarter of the London area and whose area, incidentally, goes well beyond London. The ambulance service was just one of its responsibilities. The money supply went down at about the time that the London Ambulance Board was created. Full members of the regional health authority had been on a panel managing the ambulance service and they were answerable to the Secretary of State.

During an Adjournment debate on 20 December 1989, the then Under-Secretary of State for Health, a most courteous Minister, who is not unacquainted with financial matters, made a remarkable statement about the London ambulance service, when he said: It cannot be financed as a demand-led service such as unemployment benefit or the prescription of drugs."—[Official Report, 20 December 1989; Vol. 164, c. 528.] A doctor is free to prescribe drugs—apart from being subject to sensible limits that are set after certain procedures have been followed—but he cannot even prescribe an emergency ambulance. That is what the junior Minister for Health, the predecessor but three or four of the Minister now present, said in 1989. We were then cost-capping an emergency service.

I know that the Government have changed their view a bit since then, but only after enormous pressure. But even today, after the tragedies that we have seen in London, in some respects their view has not changed.

Things got worse. The poor staff were at their wits' end and they petitioned Parliament. On Friday 7 December 1990, I presented a petition on their behalf which had been signed by more than 300 members of the London ambulance service. It said of the dispute: the root causes of that dispute have not yet been addressed and therefore unless and until there is a full and proper public examination of the financing, organisation and operation of the London ambulance service there remains a great and continuing risk to the health and welfare of all Londoners."—[Official Report, 7 December 1990; Vol. 182, c. 563.] The petition also called on the Select Committee on Health to consider the matter, but, unfortunately, the then Select Committee did not do so. I helped to create the departmental Select Committee system and I deeply regret the fact that that Committee has postponed its study of the London ambulance service yet again. I hope that this debate will help it to reconsider that decision, because things went from bad to worse.

Between December 1990 and January and February 1991, we were back in the cancellation game. On Thursday 18 April 1991, I initiated a debate on several matters relating to the ambulance service. They included up to 10,000 cancelled out-patient journeys a month; extended response times to emergency calls, which were getting longer and longer; telephone stacking of 999 calls, which was becoming increasingly common, and the limit on ambulance crews to two hours voluntary overtime a week.

In addition, some 50 dedicated and experienced ambulance officers were made redundant due to the prospective privatisation of some of the service. An error was made in ordering a computer in 1991. An application was made for self-governing status—I know that that is more political, but it was a complicating factor because the patient ambulance service was to be subject to competition, which meant that people were worried about their jobs. The London Ambulance Board was invisible and virtually unaccountable to the London public.

The debate took place, another junior Minister was in the hot seat and none of those accusations or criticisms was questioned or dealt with. The only comment was, "We will do better." At the end of the debate—surprise, surprise—the Minister announced that £5 million additional capital had just been voted a week or two earlier by the South West Thames regional health authority, of which £3.5 million was for vehicles. If that money was necessary then, it should have been necessary before. In order to get the headlines on the accepted deficiencies, the Government threw money at them. But they did not necessarily provide money for more crews—just replacement vehicles and other capital equipment.

We were told that the provisions were due to the whizzo new chief executive, Mr. Wilby, who had been appointed by South West Thames regional health authority to make everything right. But the Opposition had had some contact with that gentleman—both on paper and in other ways. We knew that he was having to act on instructions cascading down from the Secretary of State—it was national policy. The Secretary of State appointed the regional health authority, which appointed Mr. Wilby—who was accountable to the authority. The authority also appointed the London Ambulance Board. Therefore, those involved were appointees of appointees.

If, in a private capacity, you, Madam Deputy Speaker, or the Minister wanted to see the Secretary of State on behalf of a number of Members, and were told that a meeting would be granted with the Under-Secretary, I know what the response would be. We had the same response; we wanted to see the then Secretary of State for Health, the right hon. Member for Bristol, West (Mr. Waldegrave), but he would not see us and said that we must first go to see Mr. Wilby. We said that we would not because, politically, the Secretary of State was responsible. Some time later, I had a long conversation lasting two hours with that gentleman, in which we discussed his programme and his plans for executing it. I was not convinced at all by what he was saying, which did not add up in practical terms.

We tabled an early-day motion stating that the Secretary of State was undemocratic because he would not see us. We were going to tell him what was going on. Later, there were more delays, which became longer and longer and there were more and more reports. Last summer I wrote three letters—one to the Parliamentary Under-Secretary of State for Health who is present tonight, and, in desperation, a third one to the Secretary of State.

The present. Secretary of State is a well-known character who is always on the radio. She always looks as though she could join the ambulance service herself. I thought that she might be being over-protected by her private office, which is not unknown, as you, Madam Deputy Speaker, will know. I took special steps to ensure that my letter to the Secretary of State of 4 September would be read by her. I shall not quote the whole letter, but parts of it. It said: Can you doubt that consequential long and unjustifiable delays in attendance over the Orcon standard of 14 minutes is and will cost lives? The letter continued: Apart from admission of inadequacies in electronic equipment, official statements from the LAS have concentrate-ed on alleged absenteeism and a need to re-roster duties. However the Chairman of the London Ambulance Service will neither confirm nor deny my allegation to him that service is being cut by up to 20 per cent. reduction in overtime necessary to keep within budget limits. In other words., budget capping was stopping staff doing voluntary overtime. I know that there is controversy about what is necessary over the weekend, but that concerns the national agreement.

Again, I went back to the question of demand-led service. I concluded: Will we have to wait until some celebrity dies after a delay of half an hour or more for an ambulance after a heart attack—as two ladies, now dead, had to do in Newham recently—before an enraged electorate discovers that contrary to their assumption resources for the emergency ambulances are not geared to the actual demand. That was my third letter on the subject in that dreadful summer.

I had to wait 24 days for an answer. I had expected that the right hon. Lady, who is well acquainted with London affairs, for obvious reasons, to reply. Instead, it was the Under-Secretary, who is here to reply to the debate. I shall read some of his letter, which is dated 28 September. He said: The information the computer holds about ambulance status and availability may, therefore, be out of date. LAS is still, therefore, having to use allocated/despatchers to check out the status of the ambulances, when it would prefer those allocated/despatchers to be reassigned to call-taking. That was a staff matter. The next part is the most important. He said: The problem currrently faced is behavioural rather than technical and lies with a proportion of the crews failing to use simple procedures to notify their status. The CAD system itself is functioning correctly at a technical level. The crews were telling me that it was not. I said to Mr.Harris, whom I met that summer, "If you try to put this computer in, it might work, but it won't do awfully much for getting people to hopital better because of the lack of crews on the ground. Re-rostering, whatever you do with it, won't do the trick." I had hoped that the computer might work, but it did not, and we all know the result.

There was then this sentence from the Under-Secretary, who is another Derbyshire echo: The NHS, as you know, is cash limited. The onus is on NHS services to meet the demands made upon them, within budget. This cannot be achieved without good management and co-operation from staff. These expectations must apply just as much to ambulance services as they do to other elements of the NHS. In the LAS we have the technical means and human and vehicle resources to make the emergency service demand-led in the only way that makes sense, that is that ambulances are sent, quickly, to everyone who asks for one. But we need the full involvement of staff in notifying their status and within few weeks accepting new rosters. Within a month, the whole thing broke down. The Minister apparently did not even look at the problem to find out what was going wrong—as it was, and as most people knew that it would.

What was worse was that, between January 1992 and the failure of the system entirely, over 40 delays were associated with death. I am not saying that there were 40 deaths due to delays. We do not know, do we? However, I wonder whether any of the 40 sets of relatives think that. I have a list here, which was compiled from local newspapers, of those incidents, which occurred before the thing went wrong. Irrespective of the computer failure, things were going wrong.

Subsequent to the collapse on 9 March 1993, a written answer from the Under-Secretary showed that, in June 1992, 90 per cent. of the calls were within 25 minutes, but 10 per cent. were after 25 minutes. That means that one in 10 ambulances called arrived at the scene 25 minutes or more after the call went out. That does not include the time that some callers had to wait listening to a recorded message. Instead, I am talking of the time from when the control room received the call.

The story becomes worse as it continues. I had asked for information about the number of ambulances that arrived half an hour after a call. I wanted to know the exact intervals. I am sure that the Minister, when he was a Back-Bench Member, would not have accepted what he wrote to me. Unfortunately, it is an answer that all Back-Bench Members receive from time to time. His response was: A breakdown of call response times above 25 minutes could be obtained only at disproportionate cost to the London ambulance service."—[Official Report, 9 March 1993; Vol. 220, c. 499.] As I have said, 10 per cent. of ambulances arrived at the scene 25 minutes or more after being called in June 1992. The service could not give a more precise distribution of the times taken for ambulances to arrive at the scene. The Minister had the neck to allow that answer to leave the Department. I wonder whether he asked the service why there would be a disproportionate cost. It shows that those involved were not on the job. How can anyone who is in charge of a London ambulance service be ignorant of the extent of delays of half an hour or longer? Of course, the Minister's answer appeared in Hansard.

The real answer came to me in a plain brown envelope. I suppose that my question had been spotted. My goodness, the ambulance people watch this place now. I was sent a clipsheet and a five-bar-gate form. The times in minutes are entered after the first response. At the end of the form there is "26+". The form starts with 0, 1, 2, and 3, and at the end of the page there is 26. In other words, the LAS records the number of response times after 26 minutes. If the Minister had obtained an answer to my question, the LAS would have had to go through all the forms, which of course would have cost a great deal of money. It is clear, however, that the service was not monitoring what it was doing. Is that the public administration and efficiency for which we are looking?

Some London Members had had enough. The report of the inquiry showed what had gone wrong so often. Early-day motion 1498 read: That this House deplores the absence of preventative action that should have been taken by successive Secretaries of State and their departmental Ministers subsequent to receive warnings". We listed all the things that had gone wrong and said that someone should resign.

Each month there were 10,000 cancelled patient journeys. That means that over three or four months there would be 30,000 to 40,000 cancellations during 1992. That means 40,000-plus emergency service serious delays. But before things went wrong in 1992, what about 1991? Does that mean 80,000?

I tabled another question about overtime: To ask the Secretary of State for Health if she will now make it her policy to ensure that all offers of voluntary overtime by ambulances crews that would fill gaps that would otherwise occur in the scheduled rostering are not subject to budget restriction. The question was answered by the Under-Secretary as follows: All national health service providers, including ambulance services, must provide services within the resources allocated to them. It is for individual ambulance services to manage overtime levels within the overall staffing budget and to ensure that staff are rostered to provide services to the public."—[Official Report, 3 March 1993; Vol. 220, c. 172.] My goodness me! The Minister who let that by—his name is on the answer—is sitting on the Government Front Bench. This is accountability at work.

The delays are continuing, but they are fewer than they were because there has been some tightening up. The staff are keen and there is a new atmosphere. Why not let the service have the money to enable it to get crews out in ambulances, crews who are willing to do the work? I know that there are industrial relations problems. One reason for them is that the late Mr. Wilby—he is not literally dead, but he is as far as the service is concerned—would not meet people to discuss them.

It is about time to place all this on record—that is what Parliament is all about. There was an unexpected development yesterday as a result of the inquiry, which recommended certain actions. The Secretary of State wrote to South West Thames regional health authority requesting details of its plans. Yesterday, the Secretary of State wrote back to Dr. Marion Hicks, the RHA's chairman, and was pretty sharp in what she said.

The Secretary of State referred to the London Ambulance Board as something of an experiment and stated that the board and the RHA were unclear about their respective roles and responsibilities. Nor were they robust enough to respond to the computer problem facing the LAS. It is therefore right that you should replace them with a clearer and simpler set of arrangements. I understand that the London Ambulance Board has disappeared in a puff of smoke. It was fairly irregular anyway—founded upon a couple of lines in a White Paper. I tried to ascertain its statutory basis in either the 1977 or 1990 Act, but was unable to do so. Perhaps the Minister can inform the House. It was one of those hands-off affairs, but that was Government policy—originally under the right hon. and learned Member for Rushcliffe when he was Secretary of State for Health, and continued by successive Ministers.

If there was a lack of public accountability—clearly there was, because the Minister said so—that was the responsibility of the Government. Only a few years ago, a councillor in West Ham or East Ham in my constituency could have knocked on the council's door to find out why the ambulance service was not working properly. Now that has to be done in the House. What a way to run an ambulance service and a health service.

The Secretary of State's letter goes on: In the medium term, the aim must be to move the LAS towards Trust status as soon as possible, creating the normal pattern of accountability of an NHS provider. I do not know what is the normal pattern of accountability", but it is certainly not trust status—not for that sort of service.

The Secretary of State goes on: This means abolishing the Board and making the LAS Chief Executive directly responsible to the Regional Health Authority for all aspects of LAS management and performance. I thought that that was what already happened. The board appointed Mr. Wilby and he tendered his resignation to the board. What was the board doing? Presumably the board resigned so that it could be trumpeted round the country that something had happened, when it appears that the board did not have much power anyway. It was a phantom board that was not in control. Mr. Wilby was in control, but hardly anybody else.

I tried to find out from the RHA whether the public minutes recorded anything to do with the LAS, but I do not think that there is much there.

The Secretary of State's letter continues: We both recognise that to make the new arrangements work will require thorough and rigorous public scrutiny of the LAS by your Authority. That presumably means that the board of South West Thames regional health authority appointed by the Secretary of State will act for the public in scrutinising the LAS. I thought that public scrutiny related to elected representatives—whether in respect of borough councils, county councils or Parliament. How can appointed representatives scrutinise a public authority when they are accountable only to the Secretary of State who appoints them?

We have the Secretary of State trying to reassure us as recently as yesterday. The last sentence of her letter reads: I shall expect regular reports on progress from the NHS Chief Executive and will hold the RHA rigorously to account for its performance in managing the LAS. I think that we should call Ministers to account for the way in which they have mismanaged things.

I was not going to say this before I read that document, which is now in the Library. Overtime is still being capped, despite two or three requests in letters and questions; a phantom board, which did not have much responsibility anyway, has resigned; and the Secretary of State talks about confidence. In, I believe, a press release, she said that there would be no more confidence in the LAS until the appropriate steps were taken.

I suggest to the right hon. Lady that there will not be much confidence until she changes her policy, or we change our Secretary of State. In early-day motion 1498, we asked the responsible Minister to depart. The Secretary of State and the Minister are both people of integrity, but I do not think that they understand the jobs of Secretary of State and Minister if they can write such tosh in an attempt to get off the hook. For years, thousands of people in London have been subjected to suffering, grief and difficulty.

I quoted from the Minister's letter. Either he did not find out what was going on—which he should have—or he mentioned it to the Secretary of State and she did nothing. One of them is responsible, and for that reason one of them must go.

4.26 am
The Parliamentary Under-Secretary of State for Health (Mr. Tom Sackville)

The London ambulance service operates within the national health service on the same basis as any other directly managed service. It is accountable to Ministers, and therefore to Parliament, through its relevant health authorities—in this case, South West Thames regional health authority.

Mrs. Llin Golding (Newcastle-under-Lyme)

May I intervene before the Minister gets into his stride? He may be wondering why my hon. Friend the Member for Makerfield (Mr. McCartney) is not in his place on the Opposition Front Bench. No discourtesy is meant to the House, the Minister or my hon. Friend the Member for Newham, South (Mr. Spearing); my hon. Friend's wife has been taken ill, and at the last minute I agreed to sit on the Front Bench. Of course, the rules of the House do not permit me to speak.

Mr. Sackville

I thank the hon. Lady, and ask her to pass on our sympathy to the hon. Member for Makerfield (Mr. McCartney).

London has four regional health authorities, and four regions together fund the revenue and capital requirements of the LAS. The service is managed by South West Thames on behalf of the other three health regions.

All large organisations—the NHS is no exception—must operate through devolved responsibility, with clear lines of management accountability. Considerable management responsibilities are delegated to the appropriate levels of the NHS—regions, districts, family health service authorities and now trusts. Ministers are accountable for the performance of the NHS, but local management is responsible for ensuring that services are delivered. The front line of the NHS cannot be managed from the centre; it is the responsibility of the centre to see that services are well managed.

The medium-term aim for the LAS must be for it to achieve NHS trust status. Yesterday, a further 132 hospitals, community units and ambulance services achieved trust status. It is sensible to expect the LAS to achieve the same status as the great majority of NHS service providers. Until trust status is achieved, the LAS will continue to be directly managed by South West Thames regional health authority.

The recent report of the independent inquiry into the LAS identified management failures within the service, especially surrounding the implementation of a computer-aided dispatch system. The LAS has recognised that it must learn from the mistakes that have been highlighted and implement the report's recommendations if it is to achieve its main aim, which must be to improve its performance for Londoners.

As the inquiry report says, the best way, and the only way, in which the London ambulance service can regain public confidence is by making significant improvements in performance. Since the failure of the computer-aided dispatch system in October and the resignation of the then chief executive, John Wilby, performance has already improved. In the summer of 1992, a figure as low as 54 per cent. of crews were being dispatched in response to 999 calls within 14 minutes of the call being received. At the end of February, that figure had improved to 65 per cent. That is still below the patients charter standard, which is 95 per cent., and it is clearly unacceptable, but the achievements of the LAS since last summer, in particular since the failure of the computer-aided dispatch system in October, should be recognised.

The need for further improvements has been recognised by both the LAS and the South West Thames regional health authority. We should not underestimate the task facing the LAS in securing improvements in its service. When the planning of the computer-aided dispatch system began in 1990, a long and bitter industrial dispute had just concluded, leaving a legacy of very poor management-staff relations. Performance levels were poor. The LAS management had to work within that context to provide the improvements in performance which Londoners and Ministers expected to see.

Local managers are responsible for the day-to-day operation of their services. With respect to the computer-aided dispatch system, as implementation neared in 1992, the then LAS chief executive gave categorical assurances to the regional health authority that the chosen system would be introduced successfully and would contribute to improvements in performance. Given these assurances, the system was implemented. When it became clear that the computer-aided dispatch system had failed when it was reintroduced on 4 November, it was abandoned, and ambulance control reverted to a manual system. The chief executive of the LAS resigned and the deputy regional general manager was appointed in his place.

The system was introduced as a key element of the LAS plan to improve performance. The failure of the computer-aided dispatch system led directly to the independent inquiry, which was established to look into its failure and to make recommendations for changes within the LAS, in the light of its findings.

The inquiry report was published on 25 February. It identified several areas where the LAS must make practical changes to improve industrial relations, revise management accountability and reintroduce a computer-aided dispatch system. My right hon. Friend the Secretary of State for Health reported to the House at that time and requested the regional health authority to report within one month with proposals on strengthening management accountability for the LAS

On Wednesday of this week, my right hon. Friend announced the new arrangements for the accountability of the LAS which she has agreed with the regional health authority. The LAS had been managed by an arm's-length board, to which the chief executive was accountable. The board was chaired by a non-executive member of the regional health authority and had five non-executive members nominated by the four Thames regions. The LAS chief executive and other senior LAS managers sat on the board.

It is now clear that these arrangements left the members of the board and the regional health authority unclear about their respective roles and responsibilities, in spite of the fact that the individuals concerned worked extremely hard to make the arrangements work.

Mr. Spearing

The Minister said that the chief executive was responsible to the board. Was he referring to the LAS board or to the board of the South West Thames regional hospital authority? The accountability difficulties that the Secretary of State has now admitted turn very much upon that matter. Can the Minister clarify the point?

Mr. Sackville

The chief executive reported to the board, which itself was appointed by the board of the regional health authority. I agree that there is ambiguity about the extent to which the board was responsible and the extent to which it was advisory. That is precisely why the new arrangements making the chief executive of the London ambulance service directly accountable to the regional health board represent the proper way forward. However, the hon. Gentleman is right to identify the ambiguity in this relationship.

I believe that the regional health authority exercised due diligence in its management role through the annual review of LAS performance and the individual performance of the chief executive and through the monitoring of financial performance. However, the regional health authority has acknowledged that the arm's-length arrangement meant that some of the problems identified in the inquiry report were not being acted upon adequately.

As I have said, the relationship of Ministers to operational services is based on the principle of delegating responsibility for those services to the appropriate levels of management. It is important in this relationship, that, within the objectives laid down by Ministers, operational managers should have the freedom to use their delegated authority and actually manage the service.

Within that framework of accountability, the public and Ministers expect to see services delivered to as high a standard as possible. I take a very serious view of the failures highlighted by the inquiry report. My right hon. Friend has made known her determination that the mistakes identified in the report must not be repeated. Yesterday, she agreed with the regional health authority new arrangements for the management of the LAS.

The region has acknowledged that the previous, arm's-length relationship is to be replaced in May by direct-line accountability, for LAS performance, of the LAS chief executive to the regional general manager. This accountability will include routine financial monitoring, performance monitoring, the monitoring of complaints and untoward incidents, annual corporate reviews, individual performance reviews and the observance of regional health authority standing orders and standing financial instructions.

The LAS chief executive will attend regional health authority meetings, and progress reports will be submitted to the authority. These reports will be considered in public at authority meetings. In recognition of the fact that there is a need for more detailed scrutiny, in addition to the full RHA meeting, a sub-committee comprising senior directors of the RHA will be established. This sub-committee will be able to draw on advice from a group of external specialists in, for example, information technology, finance and human resources.

The advisers will advise the LAS directly, and will also have access to the regional chairman should they think that an issue is not being dealt with adequately through normal line management agreement. The LAS sub-committee minutes will be received and discussed at full regional health authority meetings. The regional health authority will be accountable to Ministers for the LAS, within the existing framework.

The virtue of the board was that it brought non-executive assistance to the LAS and gave delegated authority to the chief executive. The regional health authority does not want to remove authority from the LAS chief executive to manage the service. Interference should be kept to a minimum, and the balance of this continued delegation will be the objectives for performance agreed between the region and the LAS. These objectives will also be incorporated into the annual corporate contract between the LAS and the management executive of the national health service and will be monitored throughout the year.

The London ambulance service is not committed to producing an annual report concentrating on performance data and agreement against plan targets. The management of the London ambulance service, in conjunction with staff, are currently preparing an action plan, which will contain objectives for improving the performance of the service—improving management arrangements, reintroducing a computer-aided dispatch system, improving industrial relations and improving financial performance. More specific objectives will be agreed when the action plan has been finalised.

I am sure that hon. Members will welcome the increased openness of the LAS to public scrutiny. Regular copies of performance reports will be available to hon. Members, local authorities and interested public bodies Emphasis will be placed on clarifying the contractual relationship between the four regional health authorities and the LAS.

Mr. Spearing

I am grateful to the Minister for giving way, because I know that there is little time. He has not mentioned finance. Surely, half the basis of this issue is the petrol supply to the engine. The management jargon that he is using does not inspire confidence in me. Will he respond to the request that the budget be increased to cater for overtime? How is the future funding of the complex machine that he has outlined going to work? Will it be determined by the Treasury, the Secretary of State, the South West Thames health authority or at a meeting of the new panel?

Mr. Sackville

It will be determined in exactly the same way as in the 41 other ambulance services in this country: through contractual negotiations between the purchasers—in this case, the four regional health authorities—and the ambulance service. In that connection, the hon. Gentleman should compare the level of finance per 1,000 of population for the London service with the other metropolitan services in the west midlands, Greater Manchester, West Yorkshire and so on. He will find that the financing of the LAS is very much in line with that of other ambulance services which are turning in performance figures of 90 per cent. and 95 per cent. against a current performance figure of 65 per cent. in London.

That is the nub of the argument. The resources are there, and we are trying to find out why there is a problem in London.

Mr. Spearing

rose—

Mr. Sackville

I should like to press on.

The new arrangements are a first step towards restoring public confidence in the LAS. We recognise that that is the goal towards which we must strive. As the inquiry report pointed out, that will be fully achieved only by improved LAS performance. I recognise that considerable progress has been made since October, but a great deal more needs to be done. The new objectives for the LAS will be delivered within a time scale agreed by Ministers.

My right hon. Friend has also told the regional chairman that she will be looking to her and her management team to ensure that the main recommendations of the inquiry report are swiftly implemented and that the LAS begins to move as quickly as it can towards providing the quality of service that Londoners have a right to expect. A report will be published in the autumn, which will detail progress in implementing the report's recommendations.

I remind the House that the inquiry report stated: it is not possible to turn around LAS performance overnight … the public and its representatives must be prepared to allow the LAS breathing space to put its house in order. We shall therefore guard against unrealistic pressures on the LAS, but we shall continue to keep its performance under careful scrutiny. It is vital that the LAS should make sustained progress towards improving its service to the public. I believe that the arrangements put in place by the region provide the right framework to enable that to happen.

Mr. Spearing

The Minister is now talking about a policy programme. Let us deal with the emergency ambulance service. Whatever the merits of joining or splitting the services, the emergency service is quite different from the patient transfer service. How can a single provider. established and working, bargain with four different customers, only part of whose areas are within the LAS area, and come to an agreement? Surely the service must reach the Orcon standard, say how much it costs and then apportion the money more or less equally among the population of the four authorities. Is there any other way of doing it? How can there be bargaining about such a contract?

Mr. Sackville

It is happening across the health service. Health authorities are demanding a certain level of service and reaching agreements with providers on the price. As I said, the financing of the LAS is be no means out of line with that of other services. It receives more money than several comparable metropolitan ambulances services, some of which have performance figures that are way ahead of patients charter standards of 95 per cent. There is a great gulf.

I should like to deal with more of what the hon. Gentleman said. He has given us a long political history of the last few years in terms of contacts between him and Ministers, Adjournment debates and other such matters, but he has not tackled the question of what the fundamental problem of the LAS is, and what differentiates it From West Yorkshire, Greater Manchester and other similar ambulance services in places with similar problems.

There is general agreement that there is a long-standing problem involving industrial relations in the LAS. I do not believe that there has been total co-operation between staff and management, and excellent performance cannot be achieved without that. We hope that the current arrangements will work towards such co-operation, but we all need to come out of the trenches, and those of us who may have been tempted to support one line or the other must meet in the middle and decide how, together, we can achieve the sort of performance in the LAS that almost every other ambulance service in the country is achieving.

The hon. Gentleman knows that the chairman of the South West Thames regional health authority has invited him to meet the authority and to give it the benefit of his undoubted expertise and long interest in the matter. A letter written to him by Mr. Spry, the regional general manager, says: Professor Hicks and I have only been involved in the LAS for a relatively brief time. You have a far more extensive experience of observing the problems of the LAS. We believe that we could benefit from learning from your experience. So far the hon. Gentleman has not taken up that offer, and he replied to the original invitation with the words: I thank you for your courtesy; it may be that you are not fully aware of the long period for which I have been involved in matters relating to the London ambulance service He also gave the fact that there may be other proceedings in Parliament as a reason for not meeting representatives of the LAS. I suggest that that is not a good reason for not meeting them. It would be most helpful if he would sit down with the chairman and the chief executive of the regional health authority and share his expertise and his ideas about what he believes is wrong. We have not heard many solutions from him tonight.

Mr. Spearing

I am extremely glad to respond to that request. But, as I made clear, I thought it right that the debate should take place first—

Mr. Irvine Patnick (Lords Commissioner to the Treasury)

No.

Mr. Spearing

Oh, yes. I hear a sedentary interruption from a well-known voice. The debate had to take place first because the people whom the Minister has mentioned, and for whom I have personal respect, are the Minister's appointees. They have to carry out a policy directed from Richmond house by the Secretary of State and the Minister, whose performance and conduct I have described—perhaps at length, but necessarily so. I shall be glad to meet those people after the debate, but it is right that the matter should be dealt with first in Parliament, where the real responsibility lies.

I conclude—I hope—by telling the Minister, if he has not already seen it, that I wrote a long piece of evidence to the inquiry, which is public, and an appendix on the need to set up machinery to determine the finance necessary to meet the Orcon standard. I should be pleased to meet the Minister, the Secretary of State or the chairman of the South West Thames regional health authority, initially to discuss my evidence and my constructive proposals within that evidence, which is now public; indeed, it has been public for some weeks.

Mr. Sackville

I cannot see why this debate in the middle of the night should have delayed the hon. Gentleman meeting the regional health authority in order to give it the benefit of his expertise on the subject. I hope that the meeting will take place soon. I extend an invitation to the hon. Gentleman to come to see me any time to give me all the information. Rather than chronicling his many Adjournment debates and his various contacts with Ministers over the years, he should give us some hard facts about what he sees as the solution to the problem. We all agree that there are serious problems with the service which are not shared by almost any other ambulance service. We have got to get together to decide what they are. Political posturing will not help.

Mr. Spearing

We want funds.

Madam Deputy Speaker (Dame Janet Fookes)

Order. Hon. Members should remember that seated interventions are to be deplored.

Mr. Sackville

We must get together to decide what differentiates London from the rest of the country. If the hon. Gentleman has something to say, let him come and say it.