§ Mr. David Blunkett (Sheffield, Brightside)
(by private notice): To ask the Secretary of State for Health if she will make a statement on the London ambulance service.
§ The Secretary of State for Health (Mrs. Virginia Bottomley)
The House will recall that last October I asked the South West Thames regional health authority to commission an independent inquiry into the operation of the computer-aided dispatch system of the London ambulance service. This followed occasions on which the system had seriously failed. That independent inquiry has now reported, and I am grateful to Mr. Don Page and his team for the thorough way in which the task was discharged.
The report finds that there were a series of failures on all sides in the implementation of the CAD system. It concludes that those were attributable largely to the pace at which the new system was installed, following on from the damaging ambulancemen's strike in 1989–90.
I take a very serious view of the catalogue of errors which the report has highlighted. These errors are unacceptable and must not be repeated. In a meeting with both the South West Thames RHA and the London ambulance service yesterday, I made clear the gravity of the situation and the importance which all those concerned with the LAS will attach to the speedy rectification of mistakes and to learning lessons from what has gone before.
I remain to be convinced that the lines of management accountability between the LAS and, ultimately, Ministers are sufficiently robust. Accordingly, I have instructed Professor Marian Hicks, chairman of the South West Thames regional health authority, to produce proposals within one month for strengthening the lines of accountability. I note that Mr. Jim Harris, chairman of the LAS board, has decided to step down, with effect from Monday, in order to allow that process to proceed without inappropriate distraction.
The House should be reassured, however, that significant managerial changes have already taken place at the LAS since the report was commissioned. In particular, a new chief executive, Mr. Martin Gorham, has been appointed, following the resignation of John Wilby. He has taken considerable steps to improve both management and industrial relations at the service. I am also pleased to note that the LAS will appoint an information technology director to oversee the staged implementation of an effective computer-aided despatch system.
The House will also want to know of the significant improvements in service standards which have taken place since the autumn. 999 calls are now answered within an average of six seconds. Ambulance response times are now some 16 per cent. above the level to which they fell last summer. However, they remain well below the levels which are common in other metropolitan areas.
The report recognises that London is a special case. However, the fact that other ambulance services continue to provide a much better response time than the LAS, often with far fewer resources, must give the service and those who work for it considerable food for thought. These problems must be tackled. In particular, I wish to 1006 see an early start made to the negotiation of new rosters with the union side which will put more ambulances on the road and improve the service to patients.
I have asked Professor Hicks to provide me with regular reports on progress. We will be agreeing new objectives with the authority to achieve national standards as soon as possible. We will also want to see further improvements in the service's personnel and financial performance.
Both the RHA and the LAS itself have embraced the findings of the independent inquiry. A series of important managerial steps are now in place in response. They will improve the management of the service, management-staff relations and accountability to local people. The result will be improvements to the service for London patients, which London expects and London must get.
§ Mr. David Blunkett (Sheffield, Brightside)
I would like to pay tribute to Don Page and his team for an excellent report.
Is it not time for the Secretary of State to say sorry—sorry for the mess that was inflicted on the people of London and for the risk to which they were put? Will the Secretary of State accept that the report is a damning indictment of Government complacency, inaction and irresponsibility? Is it not time for the buck to stop, and is it not time for it to stop right here in the House of Commons?
Is it not a fact that the report describes the system as fatally flawed, introduced in what the report calls a climate of mistrust and obstructiveness, not from those working in the service but by those managing the service? As Don Page, the leader of the team described it, the issues raised by staff were swept aside. I may add that the issues raised by London Members were swept aside—swept aside from 18 April 1991, when they were first raised in the House, and swept aside last autumn by the Secretary of State and her Ministers when we tried to hold them to account for what had been taking place.
Will the Secretary of State confirm that the report shows that the only priority was implementation by the date decided, implementation at the lowest possible cost? Is it not time to review a system in the national health service which puts cuts before competence and private contracting before patient care? Does not the report spell out that there was no proper system of managerial oversight, that there was no structure for ensuring that what took place was acceptable or credible? Is it not a fact that the Secretary of State has, across the country, a system which repeats the same errors: the lack of line management responsibility and the failure of Ministers to oversee adequately what is directly within their responsibility?
Will the Secretary of State confirm that criticism in the report talked about the sweeping away of the advice of those working in the service, of quality being rejected purely on the basis of "Will it do?"? Will the Secretary of State confirm that on 28 October she told hon. Members that she would be undertaking an immediate review to prevent such chaos from happening again? Yet Don Page, when asked this morning whether sufficient changes in the system had been made by today, said:No. Today really marks the start of a new era.Will the Secretary of State confirm that on this occasion what she says will hold water and bears some resemblance to the truth? Is it not time for a new era for the NHS, not 1007 simply in London but across Britain? Is it not time to put accountability and caring before accountancy, and to bring back openness and honesty to Government dealings with our NHS?
Does the Secretary of State agree with Chris Spry, the general manager of South West Thames region, who today is quoted as saying:We all have to share some responsibility"?Will the Secretary of State concern herself with what he went on to say:This arm's-length arrangement, I sense that no one is in charge and that somehow some way we will find a way of holding people responsible will not do. The mechanisms were not helpful"?Will the Secretary of State confirm that she is changing those mechanisms, the operation of the regional structure, and oversight and accountability for the ambulance service? Is the arm's-length approach, or what Mr. Spry described as neither a fish nor fowl approach, acceptable to the Secretary of State? Will she confirm—[HON. MEMBERS:"Too long."] This is a serious issue, on which the people of London demand answers.
Will the Secretary of State confirm that a junior Minister, replying to my hon. Friend the Member for Newham, South (Mr. Spearing) on 28 September and to my hon. Friend the Member for Hampstead and Highgate (Ms. Jackson) on 21 October, said that he was satisfied with the system? Only five days before the system collapsed, he told them that the problem currently faced was a behavioural rather than a technical one. Did he not say that an inquiry into the London ambulance service would serve no purpose? Did not the Secretary of State indicate that she had given him direct responsibility for the London ambulance service? Should he not accept that lead and, as the junior Minister responsible for the mess, resign this afternoon?
§ Madam Speaker
Before the Secretary of State responds, may I bring to the attention of the House the plea that I make frequently in the House for brisk exchanges? Of course this is an important statement and hon. Members want to ask questions, but only a few hon. Members will be able to question it if long exchanges take place. I ask for briskness on both sides of the House in future.
§ Mrs. Bottomley
It is a serious report, which the regional health authority has said that it will act on immediately. I am concerned about questions of accountability. The hon. Member for Sheffield, Brightside (Mr. Blunkett) tried to extend this beyond all reason because throughout the service we have clear lines of accountability. It is one great strength of NHS trusts that such matters are so clear and successful. As I made clear in my statement, I have asked for a report within a month from the regional health authority as to whether the system of having an advisory board over the London ambulance service is the most appropriate means of securing clear lines of accountability.
As to the securing of such information technology schemes generally, the chief executive of the NHS, Sir Duncan Nichol, issued a directive to the service in January of this year, making clear how project management should work and the importance of getting tested and effective schemes in place. It is right to say that the report outlines a catalogue of difficulties in industrial relations, a spirit of mistrust and a lack of openness.
1008 The real issue to which I draw the attention of the House is the comments in the report. The report makes it clear that, if ever there was a time, now is the opportunity to cast off the constraints and grievances of the past years and start a fresh management and staff partnership. That time is now, and I commend those remarks to the House.
§ Ms Liz Lynne (Rochdale)
I should like to ask the Secretary of State when she was first made aware by the London Ambulance Service Board of the potential dangers in the computer system. If she was made aware of the potential dangers in advance, what action did she take? Did she ask for assistance from other Ministers to avert the potential crisis? Will she now put in place a Londonwide regional health authority which could oversee the ambulance service?
§ Mrs. Bottomley
When I previously reported to the House on this matter, it is not my view that all the information on which I based that statement was entirely accurate. When I spoke on the previous occasion, I suggested that the difficulties had emerged because there had been an excessive number of calls. I can tell the House now that that is not strictly accurate. More to the point, the system was suffering from overload and there were difficulties in it. That is the reason for establishing the independent inquiry.
I am very concerned that messages in the service were not properly reflected up the line. I regard the matter as serious, but I do not believe that the establishment of a Londonwide health authority is remotely the way of attacking that specific issue. The report outlines some serious matters. I wish to be satisfied that the accountability mechanisms are in place.
I should like to remind the House of the significant improvements in the service already available and of the determination of all those in the London ambulance service to put the past behind them and to build a better service for Londoners for the future.
§ Sir John Wheeler (Westminster, North)
My right hon. Friend has agreed that there have been serious management failings in the London ambulance service. Those failings are evidenced by the extraordinary and bad sick leave rate in the service which reflects partly on management and partly on the trade union attitude. That needs to be addressed as well. May we look forward to an improvement in the delivery of the service in London?
Will my right hon. Friend confirm that the service is adequately funded with an increase in expenditure? Will she also confirm that well over 300 paramedics now go out with ambulances, as against two or three a few years ago?
§ Mrs. Bottomley
I confirm all my right hon. Friend's comments. Certainly the absentee rate continues to be unacceptably high. As my right hon. Friend well knows, that is often an indicator of other difficulties. The importance of good management which is trusted is essential. I believe that Martin Gorham has made an excellent start on restoring morale and securing a more effective service for Londoners.
I can also confirm my right hon. Friend's comments about resources. There has been an increase of significant amounts–9 per cent. in the London ambulance service this year—which bring the funding to almost £70 million. We have appointed an extra 337 paramedics in the past two years.
§ Mr. Nigel Spearing (Newham, South)
Does not the Secretary of State recognise that she simply does not listen and her Ministers have not listened? On 18 April 1991, there was an Adjournment debate in which were set out all the things that were going wrong. The problems have got worse. Despite that, the Parliamentary Under-Secretary of State for Health (Mr. Sackville) said that what was going on was "behavioural rather than technical".
Does not the Secretary of State agree that her predecessor was asked to see a deputation of London Members of Parliament and refused? Her predecessor referred us to Mr. Wilby, who has now resigned. Mr. Wilby was appointed by the South West Thames regional hospital authority when a Minister of Health in another place was the chairman of that authority. Was not the Secretary of State warned by the Minister in another place that things were amiss?
Does the right hon. Lady think that we would be in this mess if the London ambulance service was run like the London fire brigade? The London fire brigade authority is run by a committee of elected London borough councillors. Would that not be the sort of accountability which is so badly missing in this case?
§ Mrs. Bottomley
I do not accept the solution advanced by the hon. Gentleman for the effective management of the London ambulance service, but I accept what he says about the importance of building up a more open system. The report makes it clear that there should be a far more open relationship between the London ambulance service and local organisations representing patients, Members of Parliament and the media. I know that the new management intend to act on that. I believe that Martin Gorham has already acted in an open fashion.
My hon. Friend the Under-Secretary who presently has responsibility for ambulance services has had many meetings with people from the ambulance service. He has, of course, made it his business to visit ambulance services in other parts of the country which deliver much higher standards with comparable resources.
§ Mr. Roger Sims (Chislehurst)
I thank my right hon. Friend for her statement, for recognising the gravity of the position and for the prompt manner in which she acted last October and today on receipt of the report. Will she confirm that response times are now much better than they were just a few months ago? Is she satisfied that having just one London regional health authority responsible for the whole of the London ambulance service is the most satisfactory management structure? Is there not a case for creating some sort of free-standing body, possibly a trust, directly answerable to her?
§ Mrs. Bottomley
I can certainly confirm my hon. Friend's remarks about improved response times. They have improved by some 16 per cent. since the time of the earlier statement. The call ringing times rightly worried many Members of Parliament. It is deeply worrying to members of the public to ring the ambulance service and wait an unacceptable length of time. In some cases an answerphone was used. That cannot be acceptable. The average call ringing time is now six seconds. That is a substantial and clear improvement.
My hon. Friend suggested that an NHS trust could override the London ambulance service. That is certainly a pattern which I would support in due course. However, I am not prepared at present to approve an NHS trust 1010 because I must be confident on several matters which still need further progress before I can take that step. It is certainly a vision towards which I should like to work.
§ Mr. Clive Soley (Hammersmith)
The Secretary of State was honest in saying that she misled the House by giving information which she now tells us she was given by managers who failed to deliver. What puzzles me is that she went on to say that accountability was not the answer. She can put in as many new managers as she likes, and for a while they may be good, but the problem with centralised, bureaucratic systems is that, without accountability, they fail. Why on earth cannot the Government get rid of the centralised bureaucratic system and introduce accountability, so that managers are genuinely accountable over a period to prevent such things happening in future?
§ Mrs. Bottomley
I made it clear in my statement that I had asked the regional health authority to report within a month on whether we had the proper mechanisms of accountability. It is clear that we must have direct, effective lines of accountability to the chief executive of the national health service, Sir Duncan Nichol, and, indeed, to Ministers. In this case, as the report makes clear, they were not adequate.
§ Mr. Richard Tracey (Surbiton)
Londoners will be glad that this further step has been taken to remedy a wholly unsatisfactory ambulance service. Other than from the report, has my right hon. Friend learnt from her conversations with others that it was not so much the failure of the computer system as a wholesale failure of industrial relations in the London ambulance service which caused so much of the problem? Is it not time for full accountability of both workers and management and for proper lines of communication which mean that the taxpayer gets proper value and proper efficiency for the £70 million invested?
§ Mrs. Bottomley
My hon. Friend has identified the issues exactly. Time and again, the industrial relations difficulties were only too clear. I still want progress on the introduction of new rostering schemes, and we know full well that they will lead to significant improvements in services for Londoners.
The report also advocates the introduction of single-table bargaining, which will also lead to substantial improvements. A number of factors are involved in such matters, and the aspects that my hon. Friend identified need further consideration. It is right that Londoners should get value for money and should have the ambulance service to which they are entitled.
§ Mr. Harry Cohen (Leyton)
Following the debacle for which Ministers do not hold themselves responsible, is it not clear that, whatever else the new management need, they need time? In such circumstances, would it not be foolhardy to push ahead with competitive tendering, which can only mean the loss of more jobs among ambulance staff? At the very least, should not the Government abandon dogma and stop competitive tendering to get the service going again?
§ Mrs. Bottomley
We have to secure value for money in the patient transport and ambulance services as well as elsewhere in the NHS. The report frequently discusses the need for more time, the dangers of setting unrealistic 1011 timetables and the importance of the public and their representatives allowing the LAS breathing space to put its house in order. The new management team, which has announced its intention to take on an information technology director, needs time to make further steady progress to improve the service for Londoners.
§ Mr. David Congdon (Croydon, North-East)
Does my right hon. Friend agree that it is dangerous to concentrate on aspects of computer implementation at LAS, because the problems that it experienced pre-date the implementation of the computer system? Is it not important that all parties involved in management and unions at the London ambulance service should get together to bring about a much-needed improvement in the service so that Londoners get the service that they deserve and rightly expect?
§ Mrs. Bottomley
I totally support my hon. Friend's comments. As is well understood, the difficulties were deep-seated. If anything, they suggest that management were trying to achieve unrealistic timetables because of long-standing difficulties. It is clear that both management and the men and women who work in the London ambulance service wish to put that behind them and to build for the future.
§ Ms Tessa Jowell (Dulwich)
Does the Secretary of State accept that capital that should have been spent on new ambulances was diverted by London ambulance service management to pay for the computer system? Does she accept that, as a result, London's emergency vehicles do not meet the chief ambulance officer's guidance that they should be replaced every three years? Does she accept my concern that 55 out of the 69 ambulances that serve my constituents in south-east London are more than five years old? Will she undertake to fund a replacement programme in line with the chief ambulance officer's guidelines?
§ Mrs. Bottomley
A large programme of vehicle replacement is already under way: 130 new vehicles were purchased in 1991–92, another 80 are being provided this year, and an additional 30 accident and emergency ambulances have recently been ordered. That is apart from the additional paramedics that my right hon. Friend the Member for Westminster, North (Sir J. Wheeler) identified and the increase in call takers, who have improved call response times.
§ Mr. John Bowis (Battersea)
Does my right hon. Friend agree that what Londoners do not need is the political, synthetic response that we heard from the hon. Member for Sheffield, Brightside (Mr. Blunkett)? They need to know that the report makes it clear that the policy decision on CAD was right but its implementation was wrong. We can now get that policy implemented correctly. Does she also agree that Londoners need to hear the good news about the ambulance service, which has been highlighted by the figures that she has already given on the improvement in paramedic numbers?
§ Mrs. Bottomley
I am quite convinced that my hon. Friend is right. The ambulance service now needs to build on the major improvements that it has already provided in its service. I ordered the report urgently and it has now been published. We have to learn the lessons from it and ensure that the ambulance service provides the service that Londoners expect.
§ Ms. Glenda Jackson (Hampstead and Highgate)
The Secretary of State referred to the misunderstanding arid mistrust in industrial relations, but is she not aware that she played a major part in creating that misunderstanding and mistrust? On 28 October, in response to a private notice question from my hon. Friend the Member for Newham, South (Mr. Spearing), on five separate occasions she blamed the then breakdown in the computer system on staff difficulties. She even said that teams in London had to understand that the computer would not work correctly if they did not press the buttons at the right time. Today she has again taken the opportunity afforded by her hon. Friends to blame the people who understand the LAS best and to whom she should be listening first—those who work in it.
§ Mrs. Bottomley
There is some merit in those remarks, because the difficulty that occurred on 26 October was caused by the receipt of imperfect and inaccurate information, which caused the computer to generate exception messages. I am afraid that the system requires perfect use throughout. I accept totally, however, that the concerns of all those working that system should have been heard. That recommendation is the most powerful part of the report.
There are and have been deep-seated industrial relations difficulties in the LAS. The report makes it clear that it is time to put them behind us. Those difficulties caused other subsequent problems—for example, the absentee rates. There is still an outstanding need to introduce the new roster arrangements. All those difficulties make it clear that there is need for improvement. I hope that urgent action will be taken to introduce single-table bargaining for a start.
§ Mr. Toby Jessel (Twickenham)
Has any estimate been made of the large number of lives that are saved each year by the LAS? Is she aware that the service must have improved, as it is months and months since I have had any complaints about it?
§ Mrs. Bottomley
There is no doubt that the LAS has turned a corner. Morale is much better and the service is improving significantly. When the system broke down in October, deplorable claims were made about lives being lost, which was the most irresponsible scaremongering. I can inform my hon. Friend and the House that on no occasion has a coroner's court concluded that delay in the arrival of ambulance could be blamed for the death of a patient. It is extremely important to put irresponsible scaremongering to rest.
§ Ms. Harriet Harman (Peckham)
All Londoners had a patients charter put through their letter box and in it the Government promised that ambulances would arrive in less than eight minutes after an accident or an emergency. What redress is available to the thousands of people who have had that charter standard broken? Will the Government apologise, or does the charter mean nothing? When does she expect that the LAS will meet the standard laid down in the charter?
§ Mrs. Bottomley
The question that the hon. Lady should ask is how it is that ambulance services in metropolitan areas are able to meet those standards. The LAS must learn how to meet the standards set by other services with comparable resources in other parts of the country. We want to see further progress from the regional 1013 health authority in meeting those national standards. I shall make such a timetable clear to the House when I am able to do so.
§ Mr. Richard Ottaway (Croydon, South)
Like everyone else, I am appalled by what happened and congratulate my right hon. Friend on the way in which she has handled the matter. She has just confirmed that the report stated that no coroner's court found that a death resulted from actions by the London ambulance service. However, large question marks remain. Three constituents of mine—Mr. Evans, Mr. Edwards and Mr. Wright—all died after waiting a totally unacceptable time for an ambulance. The wife of one of them waited eight minutes for her 999 call to be answered. Will my right hon. Friend continue her inquiries into those cases, details of which she and the inquiry have?
§ Mrs. Bottomley
As I made clear to the House, I shall insist that progress towards higher standards continues. There has been considerable improvement in a short time —a 16 per cent. improvement in the response rate and a much faster rate at which calls are answered. As my hon. Friend knows and repeated, no coroner has suggested that the delay in the arrival of an ambulance was responsible for the death of a patient. However, I well understand Members of Parliament representing London constituents wanting to ensure that progress continues. Equally, my hon. Friends and I, through the regional health authority, will make sure that there is steady, firm and determined improvement.
§ Ms. Diane Abbott (Hackney, North and Stoke Newington)
The Secretary of State will be aware that the state of the London ambulance service has concerned Londoners for at least two years. For at least two years, London Members of Parliament have tried to get Ministers to listen. Over that two years, Ministers refused to listen, refused to meet us on occasions, and refused to face the facts. What is said in the report published today has been said by London Members for at least two years.
Thousands of Londoners have been distressed and inconvenienced by the service's problems. Is the Secretary of State willing to use her imagination and put herself in the place of the many Londoners who have had to sit with dying relatives and wait unacceptably long periods for an ambulance? Delay might not have caused deaths, but is the right hon. Lady willing to use her imagination and put herself in the shoes of those people and ask herself—as those people must be asking now—when will the Government ever take responsibility for anything? When do Ministers ever say sorry?
§ Mrs. Bottomley
I have been extremely direct and open with the House. On a previous occasion, I made it clear that we would establish an inquiry and that a report would be published. The report has now been published, and 1014 once again I have made it clear that I intend to see further improvements. The Opposition wilfully fail to identify the significant improvement already taking place in the London ambulance service. I congratulate the new executive, Martin Gorham, and all those who work in the service on that. It is important that we get accountability straight and make sure that improvements continue.
§ Mr. Matthew Carrington (Fulham)
Does my right hon. Friend accept that the reorganisation of the accident and emergency service in London hospitals will place an even greater strain on the London ambulance service? Does she agree that the only way forward for the service is to follow the principles that underlay the computerised despatch system? Will my right hon. Friend ensure that, before London's accident and emergency service is radically altered, the London ambulance service manages to despatch its ambulances in the most efficient and timely manner?
§ Mrs. Bottomley
My hon. Friend again rightly identifies a matter about which all Londoners will want to be reassured. I am able to reassure them. I refer to the statement by my hon. Friend the Minister yesterday when he opened the new accident and emergency department at the Royal London hospital that there is no question of changes in any London accident and emergency departments without proper safeguards that local people will have proper access to accident and emergency services. That of course includes the reliability of the ambulance service.
§ Mr. Malcolm Wicks (Croydon, North-West)
Given that many Londoners died because of Government inaction before the inquiry was finally announced, including many in tragic circumstances in Croydon—as the hon. Member for Croydon, South (Mr. Ottaway) noted—will the Secretary of State comment on the concept of ministerial responsibility? Where in the Department of Health is to be found honour?
§ Mrs. Bottomley
As I have made very clear, no coroner's court has found that the death of a patient could be attributed to delay in the arrival of an ambulance. It is important to emphasise that, and I am not prepared to tolerate comments from hon. Members implying otherwise. I have also made it clear, however, that Ministers must be satisfied about clear lines of accountability, and it is a source of deep concern that the report identifies difficulties in that regard. That is why I have made it plain that, within a month, I want a report from the regional health authority, establishing whether the structure of the London Ambulance Service Board provides the most appropriate way in which to satisfy the chief executive, and Ministers, that those lines are clear and effective.