§ Mr. Nick Ainger (Pembroke)
I have requested this debate today because, although the Pembrokeshire ambulance service operating as part of the Pembrokeshire national health service trust offers an excellent, cost-efficient, fast and effective service to the people of Pembrokeshire, that service is under threat for the second time in the space of a year.
Last summer, the Welsh Ambulance Policy Advisory Group—WAPAG—consisting of the chairmen and chief executives of each of the Welsh ambulance trusts, proposed a reconfiguration of ambulance services in Wales, forming three new health trusts. It was proposed that the whole of Dyfed Powys and Morgannwg health authority areas be covered by one ambulance trust—the Mid and West Wales ambulance trust—that north Wales be covered by another, and south Wales by a third. The existing trusts were to be dissolved and replaced by the new trusts in April 1997. The proposed Mid and West Wales ambulance trust would cover a geographical area of 1.2 million hectares and a population of 976,000, and would have a road length of more than 16,000 km.
A massive campaign was organised in Pembrokeshire by Unison in the ambulance service, by the community health council, by town and community councils, and by local representatives of all political parties. This morning, I welcome some 27 people from all over Pembrokeshire, who represent town and community councils, and Unison representing the ambulance service. They have collected more than 60,000 signatures in a petition opposing the abolition of the Pembrokeshire ambulance service. I shall present that petition on the Floor of the House tonight.
Following the campaign and the objections to the proposal from the Pembrokeshire NHS trust and SEWAT—the South and East Wales NHS ambulance trust—it appeared that the plans for centralisation of ambulance services in Wales had been quietly dropped. The people of Pembrokeshire breathed a sigh of relief—but that was not the end of the story.
In the guise of evaluating the response of the eight-minute Orcon standard, WAPAG produced in December a project initiation document, the objectives of which included looking again at the configuration of ambulance services in Wales. The document states:encouragement to proceed has been received from the Under-Secretary of State for Health"—that is, the Welsh Office Minister who is on the Treasury Bench today. WAPAG intends to submit joint proposals to the Welsh Office by June 1997, with a view to public consultation in autumn 1997 and introduction of the new trust arrangements in April 1998.
My main concern is that those proposals will again involve the abolition of the Pembrokeshire ambulance service. The prediction is that WAPAG will produce a report stating that there should be one ambulance service for the whole of Wales, possibly managed as three divisions—in other words, a rehash of the original WAPAG proposal for three ambulance trusts, but under a single Welsh badge. That could be, quite literally, a tragedy for Pembrokeshire and for the rest of Wales.
Part of the proposal is to evaluate a single ambulance control for Wales, but that would remove the tremendous advantages that come from having local ambulance 303 controls, such as the ambulance control in Pembrokeshire, which is based at Withybush general hospital. A centralised management system with central control lacks the flexibility to respond to a range of incidents, including major events in remote parts of Wales such as Pembrokeshire.
Even if control and management were in a divisional tier—for example, if it were based at Swansea—in the event of a major incident at one of the oil refineries at Milford Haven, incident control could be established only when the major incident team had collected a major incident vehicle and driven the 60 miles from Swansea, arriving up to an hour and half after the notification of the start of the incident. By that time, without an incident control assessing the on-site risk, the first local crews to reach the scene could have been seriously injured through being dispatched into a dangerous area with no prior on-site assessment. That happened on board the Pointsman—a tanker on which there was a series of explosions resulting in deaths in 1984 at Milford docks.
That problem could be overcome by operating in the same manner as the fire service, with local divisional offices, five of which would be needed to man a 24-hour, seven-days-a-week rota in Pembrokeshire alone; but that would add at least £100,000 to ambulance service costs in Pembrokeshire, thus wiping out any marginal savings from centralised control and management of the ambulance service. On an all-Wales basis, using the unitary authority areas, that would mean additional costs of at least £1.2 million.
The local control considerably expedites the emergency response, which is even more vital now that all British Telecom 999 services come from Cardiff, and the control staff are regularly faced with misdirected calls, or have to interpret the whereabouts of visitors who have no local knowledge.
On a day-to-day level, there are significant advantages to local control within the district general hospital. It gives the hospital advance warning of building pressures as emergency work levels rise; enables discharges within an hour that are required to free beds for incoming emergencies; and saves £150,000 per year compared to manning a separate control, a hospital switchboard and community nurse communication system.
Throughout peak periods during the past two years, Withybush was the only hospital in the south Wales corridor to continue to admit emergency cases. At no time did the accident and emergency department based at Withybush hospital have to close its doors—unlike every other accident and emergency department in district general hospitals in south and west Wales, all of which have had to close at some time during the past two years.
The ambulance service in Pembrokeshire benefits enormously from the commitment of its staff and from a modern standardised specialist fleet carrying the equipment necessary to tackle the sort of emergencies faced in the area; but that was not always so. In the early 1980s, when the service returned to Pembrokeshire, it inherited a dilapidated and rundown fleet and disheartened staff who had no clear sense of identity with the service. Now the staff have built a team spirit and developed a range of specialist new skills and services.
Ambulance personnel have been integrated into the cliff rescue teams that are situated around the Pembrokeshire coastline, and the commitment of the staff is such that all 304 the training and exercises involved have been carried out in their own time and at no cost to the NHS trust. Those taking part in paramedic training have also put in many hours of unpaid overtime.
There is a danger that that sort of dedication would quickly evaporate in a large ambulance trust with no sense of identity and serving many different hospitals. A medical priority dispatch service has also been introduced, enabling ambulance staff to give assistance over the phone that will help to save lives. Pembrokeshire ambulance service has consistently met Orcon standards, which are traditionally very difficult for a rural service to achieve. Again, that is down to the commitment of the management and staff.
Remote management of ambulance services on an all-Wales basis, or through the three-trust model, would reinforce the technical needs of the service for digitised geographical information systems, computerised ambulance location systems and computer-aided dispatch systems. For a large central control, those typically cost approximately £500,000 per system, and their performance has been patchy to say the least, especially in the mountainous terrain that covers most of Wales. With local knowledge, good relations between ambulance crews and control and good working systems between local doctors, hospital consultants and the ambulance service, the public get a better service, without the need for such expensive technology.
The proposal to create either one or three large ambulance trusts clearly poses a threat to the quality of the service in Pembrokeshire and the rest of Wales, but it is also likely to lead to large cost increases. The document prepared by WAPAG for the Welsh Office last year, which attempted to justify the merger of ambulance services in Wales, compared the unit cost incurred by the Pembrokeshire ambulance service with forecast equivalent figures for the proposed Mid and West Wales ambulance trust. Out of five areas performance-costed, the present arrangements under the Pembrokeshire NHS trust were found to be substantially cheaper per unit in three categories, and only marginally more expensive in the other two, than the estimated cost for the proposed new ambulance trust.
The cost of every 999 call attended would rocket from £230.72 now in Pembrokeshire to £265.29 under the proposed Mid and West Wales trust. The cost of the ambulance service per head of population would increase from £11.66 to £12.59, and the cost of each medical services staff member would increase from £32,317 to £38,776.
The Pembrokeshire ambulance service is recognised as a local service. The proposed changes cannot be justified on the grounds of cost or benefit to patients; the only motivation is to tackle the disaster that is SEWAT—a complete failure, because it was too big, inefficient and failed patients—but one does not solve a problem like SEWAT by creating what is potentially an even bigger disaster.
Obviously, that is not a reason to disband a highly effective service which has local knowledge and the expertise to deal with the types of incidents likely to arise in Pembrokeshire, or a good enough reason to throw away the advantages of the relationships that have been built up between the ambulance service, the hospitals and the doctors in the trust.
305 The Minister has expressed his support for the WAPAG review, both to the group and in a written answer to me. The project initiation document dated 3 December 1996 states:encouragement to proceed has been received from the Under-Secretaryof Statefor Health",and the Minister told me in his written answer:I welcome the work being undertaken by the Welsh ambulance policy advisory group."—[Official Report, 28 January 1997; Vol. 289, c. 159.]However, in encouraging WAPAG in that project, he is supporting further moves away from local control of the health service in Wales, promised by the Conservative party before the last general election.
In April 1996, the number of health authorities in Wales was reduced from eight to five, with Pembrokeshire losing its health authority. The Pembrokeshire health authority was swallowed up by the huge Dyfed Powys health authority, covering half the surface of Wales. Control and influence has been removed from local areas to faceless management in distant locations. Any centralisation of ambulance services will further strain people's identity with their supposedly local health service.
Given the considerable advantages of the locally based Pembrokeshire service, in which other hospital trusts have expressed a great deal of interest, WAPAG should now ensure that the benefits of the Pembrokeshire model are fully evaluated, with a view to applying them throughout Wales, instead of choosing a huge, centralised single trust, or the three-trust model, both of which will be costly and may lead to a deterioration in the quality of service provided, not only in Pembrokeshire but throughout Wales.
My hon. Friend the Member for Cardiff, West (Mr. Morgan), who visited Withybush general hospital last year and saw the control arrangements for the ambulance service, and who will in the next few weeks take up ministerial responsibilities for health in Wales under a new Labour Government, has assured me that he will ensure that any review of the ambulance service in Wales closely examines the locally based model that has been so successful in Pembrokeshire. I urge the Minister now, in the last days of his Government, to give a similar assurance, and remove from the Pembrokeshire ambulance service the threat that he has, until today, encouraged and supported.
My hon. Friend the Member for Ceredigion and Pembroke, North (Mr. Dafis) also wants to make a contribution, and I now conclude my remarks; but I remind the Minister that the health service in Pembrokeshire was a major issue in the 1992 general election campaign, and I am sure that his responses today will be part of the forthcoming general election campaign.
§ Mr. Cynog Dafis (Ceredigion and Pembroke, North)
I am grateful for the opportunity to speak briefly on an important subject. I want to raise an issue of which the hon. Member for Pembroke (Mr. Ainger) is aware—the 306 ambulance service in north Pembrokeshire—and to point out that there is significant concern about levels of cover and response times there. That concern has led to a demand for the establishment of an ambulance station in Crymych, and the offer by the local community council to provide the land and the building for such an ambulance station—an offer that should not be lightly dismissed.
I have been in correspondence on that subject with many people, including the Minister. The chief executive of the West Wales Ambulance NHS trust, Mr. Butcher, tells me in a reply to a letter from me that that is a matter not for him but for the health authority, because it is the authority that will have to contract for the continuing cost to the service even though the basic infrastructure—the building—would be provided free, and he says that the health authority would probably say that it could not afford to deliver that service.
We know about the financial problems of the Dyfed Powys health authority. Those issues need to be addressed by the Welsh Office in terms of the funding of the health authority. In view of the lack of movement on that matter, one must ask, how do the health authority, the trust and all concerned propose to ensure that the eight-minute response time for immediately life-threatening conditions recommended in the NHS Executive review on the ambulance service is met? That response time applies to rural and urban areas, in recognition of the fact that there should be equality regarding such an important service.
Mr. Butcher writes that methods other than the establishment of an ambulance station in Crymych might be developed to ensure that the response level requirement is met. He suggests that there should be more co-ordination between the two trusts. Currently, the ad hoc arrangements that exist for co-operation between the West Wales and the Pembrokeshire trusts are very much a one-way affair.
The Cardigan ambulance has made 121 calls in the past eight months in north Pembrokeshire to meet demand there. By contrast, there have been only two calls by the Pembrokeshire ambulance in Ceredigion itself. I understand that that service from Cardigan to north Pembrokeshire imposes significant strains on the service, which can no longer be ignored.
Unless we get an ambulance station in Crymych, the responsible bodies must come together to ensure that the response times that will be required and which should be delivered are delivered in that area. The people of that part of Pembrokeshire are very worried about that.
§ The Parliamentary Under-Secretary of State for Wales (Mr. Gwilym Jones)
I am glad to have the opportunity to respond to the points that have been made by the hon. Members for Pembroke (Mr. Ainger) and for Ceredigion and Pembroke, North (Mr. Dafis). I hope to be able to give considerable reassurance to people in Pembrokeshire and to those who take a close interest in Pembrokeshire ambulance provision.
I regard ambulance provision as an integral part of health care, vital to our well-being. Especially in recent years, the Pembrokeshire ambulance service, although relatively small, with a staff of slightly more than 60, has proved to be committed to providing the best quality for Pembrokeshire patients. We can see that in many ways, not least in the fact that it has met patients charter standards.
307 Last year, the Pembrokeshire ambulance service responded to 95 per cent. of emergency calls within 21 minutes, and more than 50 per cent. within eight minutes. That is a considerable achievement, given the rurality of Pembrokeshire and the unmarked roads in the more sparsely populated areas. I am sure that that is a tribute to the ability and commitment of all who work for Pembrokeshire ambulance, most obviously the drivers but equally everyone else involved.
Here I find myself in full agreement with what the hon. Member for Pembroke said about those working for Pembrokeshire ambulance. The excellent response rate was also achieved despite an 8 per cent. increase in emergency calls over the previous year.
On paramedics, the Pembrokeshire ambulance service has again shown its resourcefulness in meeting our requirement that each front-line ambulance should be manned by at least one fully trained paramedic. Pembrokeshire expects to be able to comply by June this year, and would have done so earlier, but for the ill health of two staff members. The Government firmly believe that getting a fully trained paramedic to the scene of an incident as quickly as possible is the right way to save lives.
Almost 8,000 emergency and urgent patients and about 63,000 other patients were carried by Pembrokeshire ambulance service in 1995–96. The staff deserve the highest commendation that we can offer them.
The hon. Member for Pembroke makes much of what he calls the threat for the second time. He indulges in wild exaggeration, which is typical of someone who prefers to live in the realm of conspiracy theories. Inevitably, the reality is entirely different from what he claims.
I have been impressed by the various organisations and individuals who have taken an interest in the proper question of ambulance provision in Pembrokeshire. I have read all the letters, and it is appropriate to refer to them.
The clerks of Haverfordwest town council, Neyland town council, Havens community council, Fishguard and Goodwick town council, Milford Haven town council, Pembroke town council, Redbaxton community council, Burton community council, Llangwm Hook community council and Narberth town council all felt it necessary to write to me. Mr. H. E. Baker of St. Florence, Tenby has written, as has, not surprisingly, Mrs. Val Sanders, the agent of the Carmarthen West and South Pembrokeshire Conservative and Unionist Association.
Later today, I will be meeting Mr. O. J. Williams, who is bringing a representative of Pembrokeshire ambulance service to see me. I will be in Crymych next week at the invitation of Mr. Robert Buckland to see the situation there at first hand. Some hon. Members may not know that Mr. O. J. Williams is the prospective Conservative candidate for Carmarthen, West and South Pembrokeshire, and Mr. Robert Buckland is the prospective Conservative candidate for Preselli and Pembrokeshire.
That is the distinguished list of people and organisations who have made representations on the matter, which I have carefully noted. I acknowledge that the hon. Member for Pembroke has asked me four questions on the matter—three last May and one in January—and the hon. Member for Ceredigion and Pembroke, North (Mr. Dafis) has written to me twice on the subject of ambulances in Pembrokeshire.
308 The hon. Member for Pembroke gave the game away in his concluding remarks, when he referred to the last general election and the coming general election. He has suddenly woken up to the matter of Pembrokeshire ambulance service, because of the activities of O. J. Williams and Robert Buckland. It is another example of a nervous Labour Member of Parliament in a very marginal seat who has decreasing confidence in the possibility of his being in the next House of Commons.
I must tell both hon. Gentlemen that any proposals to reconfigure overall ambulance provision are matters for the ambulance trusts and those involved with ambulance operations in the case of Pembrokeshire, in conjunction with their respective commissioners—health authorities and hospital NHS trusts.
I have not asked for an expression of interest to change the shape of ambulance trusts anywhere in Wales, or set any timetable for its submission. I am surprised by the fears expressed about a review being undertaken by the Welsh Ambulance Policy and Advisory Group to determine how ambulance provision can be improved. Indeed, I would be more worried if NHS trusts were not constantly looking for improvements, particularly when the most important priority is the constant pursuit of higher standards for patients through quicker response times for the most urgent cases.
The group's review involves and is supported by all Welsh ambulance operations, including Pembrokeshire's. The group intends to maintain good communications with representatives of health authorities and other NHS trusts. I and the Welsh Office health department have made it clear that, in the interests of improvements always being considered, the work being undertaken by the group is welcomed.
I emphasise, however, that that work has not been requested by me or by any other or previous Minister in the Welsh Office; nor is the group's work being paid for by the Welsh Office.
§ Mr. Ainger
In the original WAPAG document produced last summer, only one choice is offered—three trusts covering the whole of Wales. The second document, dated December, giving a project overview, states:The programme of work set out in this PID follows from the outline expression of interest developed by the WAPAG reconfiguration team and the commissioner attitude survey undertaken by Grant Thornton. Subsequently, encouragement to proceed has been received from the Under-Secretary for Health and WAPAG agreed to submit joint proposals to the Welsh Office by June 1997.How can the Minister deny that?
§ Mr. Jones
I have just told the hon. Gentleman, as I said to him in answer to the question that he asked in January, that such work is always welcome. I would be disappointed if health professionals in Wales were not giving serious consideration to ways in which provision could be improved, in relation to ambulances or any other activity of the NHS.
§ Mr. Rhodri Morgan (Cardiff, West)
The Minister cannot wriggle out of the question. The document by the chief ambulance officers in Wales through their membership of WAPAG referred to specific encouragement by the Under-Secretary of State, whom I understand to be the hon. Member for Cardiff, 309 North (Mr. Jones). He cannot wriggle out of the question by saying that there is a general move towards achieving quicker response times. There is a reference to specific encouragement by him for the submission of the second document. Is he denying that, or is he saying that the people on WAPAG do not know what they are talking about?
§ Mr. Jones
The situation is as I said. I know that it would not be understood by the hon. Gentleman, who constantly displays his lack of understanding of the health service in Wales. I have not asked for any particular thing to be done, I am not directing it, and I am not paying for it, but I would be disappointed if any part of the health service in Wales was not giving serious professional consideration to improvements. Only after such consideration can we find ways forward.
It is clear that there is great strength of feeling on several matters. I have emphasised how essential it is for any review to address all the possible options, and for it to be based on hard information, and to reach conclusions about genuine patient benefits and value-for-money savings. I expect all those involved with ambulances to co-operate in providing whatever information is necessary.
I am aware of the group's objective to submit joint proposals for the future provision of ambulances in Wales by June this year. If the proposals include a possible reconfiguration of NHS trusts—I would consider proposals only if they clearly demonstrated benefits to patients and value for money—they would be subject to public consultation in the usual way.
I readily reassure the House that the group is a useful body, consisting of the chairmen and chief executives of the various ambulance NHS trusts in Wales. The group provides a good consultative forum for developing ambulance policy initiatives and best practice. One of my officials is generally invited to attend as an observer. That enables the Welsh Office to keep in touch with ambulance operation and secure good advice from the professionals on policy development. It is a further welcome sign of NHS trusts working together to provide better health care for the people of Wales.
§ Mr. Jones
I give my fullest commitment to the best possible provision of ambulances in Pembrokeshire and throughout Wales, but that must be evolved locally. I cannot anticipate whether there will be any change. I shall certainly not impose any change. If proposals come forward, they must all be subjected to the fullest consultation locally. Only then will I consider them.
While I shall bear in mind value for money, my overriding consideration will be whether proposals will benefit patients. All I am interested in is whether any proposed changes will bring about improvements in Pembrokeshire, west Wales or elsewhere in Wales, rather than Opposition Members' ridiculous conspiracy theories.