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§ Mr. Colin Breed (South-East Cornwall)
I am sure that the Minister shares the view that time seems to stand still for people who dial 999 and ask for the ambulance service. Every second seems to be a minute, and every minute an hour, until they hear the siren and see the blue flashing light—a heart-stopping moment in the rear-view mirror for most of us. For those who have picked up the telephone, the ambulance's arrival is a moment of comfort, security and help. The time between their telephone call and the ambulance's arrival is critical.
I shall describe three short scenarios. Let us think of a pregnant woman in north Cornwall who goes into labour early at 2 am. Very distressed, she phones for an ambulance to take her the 50 miles to hospital. Let us think of a young cyclist, who has been knocked off his bicycle in a road traffic accident in the middle of Somerset, and is lying unconscious in the road while somebody grabs a mobile phone to call an ambulance to take the boy to hospital. Or let us think of members of an ambulance team who are suddenly called to a major incident at the end of a long shift. They arrive at the scene, attend the victim and take him to hospital. The hospital, which has received enormous investment in recent times, has all the high-technology equipment and the most wonderful intensive care facilities, and trained staff are ready, willing and able, but the ambulance, which has done 300,000 miles, arrives five minutes too late. Those are not isolated incidents; such events happen.
The West Country Ambulance Services trust is one of the largest ambulance services in the country. It serves the counties of Devon, Cornwall and Somerset, covering approximately 5,700 sq m of a predominantly rural area. Last year, it was one of only four trusts to fail to meet the national targets set by the Government. It managed to reach 90.4 per cent. of emergency calls within 19 minutes—well under the target of 95 per cent. It responded to 42.9 per cent. of calls within eight minutes—substantially under the expected 50 per cent.
In April last year, new standards were introduced for some ambulance services, moving away from the old Orcon standard, which specified the 95 per cent. and 50 per cent. targets, to a criteria-based dispatch. For the West Country Ambulance Services trust, that means that it must respond to 75 per cent. of immediately life-threatening illnesses within eight minutes, and 95 per cent. of all other cases within 19 minutes. Other emergency services can be used to respond to calls, although the cost of training and of ensuring that such response vehicles are properly equipped will inevitably cut into the ambulance service budget, and, therefore, not help it to try to achieve the targets.
Over the past four years, the performance of West Country Ambulance Services has become progressively worse. That is not a result of the trust's inefficiency. Nor does it indicate that the service is lacking dedicated, hard-working staff. It reflects the fact that the ambulance service does not have sufficient funding to meet the Government's targets.
Between 1993 and 1998, there was a 35 per cent. increase in emergency calls resulting in a response. That is higher than the national average of 31 per cent. Figures show that the West Country Ambulance Services trust's 356 performance standards are dropping. The ambulance service is being asked to cope with ever-increasing demand, while under constant pressure to find cost savings. The ambulance service is the front-line emergency service, and we simply cannot allow standards to drop any further.
One of the fundamental problems for all health services in the south-west is that the overall funding formula does not reflect the real cost differences associated with the sparsity of the area. The funding formula provides for an allowance of 0.5 per cent. of available funding to be allocated on the basis of population sparsity, but such weighting in no way reflects the actual cost of providing services.
Call-out times are inevitably longer, and the cost of providing ambulance cover to scattered hamlets is obviously much higher than in a densely populated urban area. In addition, the south-west experiences an influx of tourists each year, resulting in a massive increase in population. The allowance in the funding formula does not take into account the fact that the daytime population in Devon and Cornwall doubles in the summer months.
We acknowledge that the emergency ambulance cost adjustment includes a small sparsity allocation. However, figures from the House of Commons Library show that, for most west country health authorities, the EACA rises slightly as a result of the sparsity adjustment, but is pushed down by the supposed low proportion of emergency journeys. That is surprising in the light of the fact that the increase in emergency calls to which I referred results in a higher than national average response in the west country. West Country Ambulance Services predicts a shortfall in its funding next year of £700,000.
§ Mr. John Burnett (Torridge and West Devon)
Does my hon. Friend agree that it is impossible to reconcile 3 per cent. so-called efficiency savings with the additional burden of a 6 per cent. rise in call-outs?
§ Mr. Breed
That is absolutely correct. The service is expected to find 3 per cent. so-called efficiency savings, although one must consider extra burdens such as millennium compliance costs, which have fallen squarely on the authority. Staff pay accounts for 80 per cent. of trust costs. The trust is overspent on pay budgets, and therefore any deficit will have to be met from within such budgets. In order to keep within them, additional staff will not be called in when, for instance, someone is off sick. Instead, spare crew members will have to be allocated to other vehicles. That may mean that, at times, vehicles are without crews. The trust has also been forced to drop planned shift cover in order to curb overspend.
Last year, a target was set of reducing shift cover by 40 hours in each of the 11 station officer's areas. In order to eliminate overspend completely, the ambulance service would need to reduce shift cover by a further one fifth. Although reducing shift cover is the quickest way in which to compensate for the overspend, other initiatives may have to be implemented, such as a vacancy freeze, a freeze on non-clinical training and, very worryingly, slippage of some clinical training into the next financial year. None of those measures will enhance response times. Recent NHS pay awards and the implementation of the working time directive also concern the ambulance trust.
357 I acknowledge that the Government have allocated £100 million as part of the modernisation programme, but trust estimates show that that will account for only 0.6 per cent. of the additional funding required. For Cornwall and Isles of Scilly health authority, every 1 per cent. above the 2 per cent. inflation funding represents £41,000. That is the equivalent of one operational crew working for 40 hours a week.
Clearly, such cost-cutting exercises will not help the already overstretched service to try to meet national targets. The south-west yet again loses out under targets that are set for the entire population of the country. Targets for Cornwall have been reduced to 87 per cent.—8 per cent. lower than the national average. Just why the people of Cornwall are expected to accept lower standards has never been fully explained.
I am sure that everyone will agree that the ambulance service has a basic need for a reliable vehicle fleet. Ambulance staff already feel that the fleet is far from satisfactory. As I said earlier, some vehicles have almost 300,000 miles on the clock. Many old vehicles with such high mileage are still in frequent use. As the vehicles get older, they will inevitably be less reliable. This year, the ambulance service will need to replace 41 vehicles if its fleet is to be made up of vehicles under seven years old, but it can afford to replace only nine of them. No doubt the service will not forget that it had to replace vehicles in the not-too-distant past because their wheels were coming off.
The service must also meet the cost of warranties and maintenance for newer vehicles. According to UNISON, to which I am extremely grateful for providing information, a significant number of newer vehicles in the fleet will soon be outside their warranty period. That will mean that additional costs for repairs to those vehicles will fall on the trust rather than the supplier.
The effect of draft proposals by the committee for European normalisation—something that, I confess, I had not fully understood until recently—to standardise ambulances will also place disproportionate cost pressures on the west country ambulance service. The new regulations will involve phasing out the old two-stretcher ambulances and will effectively make it necessary to dispatch two vehicles to an incident where there are likely to be two casualties. Vehicles will, therefore, have to travel more frequently, which not only increases mileage, but reduces cover. It is important to remember that fuel consumption, which is a major cost and a great concern to the ambulance service, will rise considerably if the proposals are accepted and additional vehicles must attend incidents.
The proposals will also have a great impact on the St. John's Ambulance Brigade—the voluntary charity to which I am sure we all want to pay tribute—which supplements the ambulance service on an enormous scale. The charity purchases its vehicles, which are usually second-hand, from the ambulance trust. It is considering whether it will be able to continue to do so under the new regulations, and that is causing concern.
The plain fact is that the west country ambulance service does not have sufficient resources to meet national targets. The public have a right to expect ambulance staff to arrive on the scene of an incident as quickly as possible. The scenarios that I outlined earlier are true cases and are not isolated incidents. There is no cheap fix. If the 358 ambulance service is to be able to provide professional care and meet the targets specified by the Government, it must be able to afford the appropriate vehicles and provide the adequate level of staff and training.
The Minister ought to agree that, at the moment, the west country is losing out in many respects simply because the funding formula does not reflect the increased costs involved in providing that essential front-line emergency service for people living in rural areas. Our ambulance service is expected to bear those costs year in and year out for millions of tourists and the local population.
Finally, I want to remind the Minister of a fact of which I am sure he is aware, but which is often forgotten. The people of the west country fund, by voluntary contributions, two air ambulances. Week in and week out, people dedicate themselves to raising the money to keep those air ambulances going. People in Devon, Cornwall and Somerset put their hand in their pocket because they believe that it is a vital service, but people in Scotland and London benefit from air ambulances funded by the Government. That fact alone ought to mean that the Government should at least ensure that land ambulances receive all the necessary funding.
It is time for the Government to recognise that the West Country Ambulance Services NHS trust is severely underfunded. It cannot bear any more so-called efficiency cuts. Targets will not be met if there is a reduction in the resources available. The dedicated staff are struggling to meet the Government's targets with inadequate resources. I hope that the Minister will accept his responsibility and consider providing a fair formula to deal with that worrying situation.
§ The Minister of State, Department of Health (Mr. John Denham)
I congratulate the hon. Member for SouthEast Cornwall (Mr. Breed) on securing this debate on a subject of such importance to his constituents and those of other hon. Members from the south-west who are present.
The Government have made it clear that high-quality care should be at the heart of the national health service. That applies to ambulance services, which provide the public and patients with round-the-clock emergency care and access to the full range of clinical services. Ambulance services are at the forefront of the modernisation programme set out in the White Paper, "The New NHS", which involves embracing new technologies to support better and faster patient care and playing an important part in the development of NHS Direct.
I share the hon. Gentleman's concerns about the inability of the West Country Ambulance Services NHS trust to meet the national standards for ambulance response times. That is a serious concern, and the local health authorities and the trust must work together to ensure that national standards are met.
I recognise the hard work and contribution of all the staff of the West Country Ambulance Services NHS trust who last year responded to nearly 90,000 emergency calls within the 19-minute target—more than ever before. In the past few years, the trust has experienced a steady rise in the number of 999 calls made to the service. Since 1993–94, the number of emergency calls has risen by over 44 per cent. to more than 105,800 last year.
359 Two initiatives are likely to have a major impact on the ability of the trust to deliver improved response times: criteria-based dispatch, which the hon. Gentleman mentioned, and NHS Direct. Last April, the trust introduced criteria-based dispatch, which is a method of prioritising all 999 calls into three categories: category A consists of calls about situations that are immediately life-threatening, category B calls relate to serious situations and category C calls relate to situations that are not life-threatening or serious.
By 2000–01, all ambulance trusts should have introduced call prioritisation systems and are expected to meet an interim new standard of responding to 75 per cent. of all category A calls within eight minutes. Category B and C calls should continue to be responded to within 19 minutes. Criteria-based dispatch is, therefore, an attempt to answer emergency 999 calls according to the seriousness of the patient's illness and not, as in the past, according to where they live.
I emphasise that category C calls are still included with category B calls in having to be answered within 19 minutes. Those calls make up about a quarter of the total emergency calls and the Department of Health recognises that the practice of responding to them in exactly the same way as to life-threatening emergencies needs to be carefully evaluated to ensure that valuable NHS resources are best deployed in providing first-class emergency care.
Ambulance services have been lobbying in the past couple of years to be released from the convention that every 999 call requires a fully crewed and equipped ambulance. They say that if they were freed from that obligation, they could concentrate on response times to the more serious emergencies.
Work by Sheffield university and the experience of ambulance services over the past two years with 999 call prioritisation shows that it is safe and reliable, and that there may be a case for considering different approaches to minor 999 or category C calls. However, the Secretary of State stated clearly at AMBEX 98 that before there was any change to the current system of sending an ambulance to all 999 calls, there was a need for careful piloting of alternative responses to category C calls.
§ Mr. David Heath (Somerton and Frome)
Does the Minister recognise that apart from the response time for an ambulance to arrive at the scene of an incident, a further problem in the west country is the distance to accident and emergency units, which are widely dispersed in rural areas such as the south-west? It takes a long time for an ambulance to get to a hospital, so there is a double bind for the patient.
§ Mr. Denham
I am not sure whether the hon. Gentleman was listening to what I said. What he says is a fact of geography. I was setting out the measures that are or could be in hand to enable the ambulance service to deploy its resources most effectively to the patients in most urgent need.
The NHS executive intends to issue a health services circular in March outlining our approach to category C pilots in more detail. The circular will require ambulance services to register all category C pilots with the 360 executive. It will also stress the need for careful evaluation of the pilots before any decision is taken to change the current system, which enjoys huge public confidence.
Early indications are that many of the pilots will include linking appropriate category C calls into NHS Direct, which seems sensible. Any request from the West Country Ambulance Services NHS trust to register a category C pilot will be considered carefully by the NHS executive. Before such schemes are introduced, health authorities and the ambulance service will be advised to have locally agreed procedures and standards in place for dealing with minor emergencies. The pilots, as well as those procedures and standards, would need to be supported by the professions, take account of local concerns in the community and be properly explained to the public.
The second initiative that will have an effect on ambulance response times is that from April this year, the ambulance trust, in co-operation with local NHS trusts and general practitioner co-operatives, will be providing NHS Direct across the four health authorities in the south-west. NHS Direct is a major element in our efforts to use new technology and better information systems to provide faster care more conveniently. By the millennium, NHS Direct will cover up to 60 per cent. of the population in England.
Evidence from our pilots so far is that there is a great potential for the new service to assist in the handling of category C calls. It is also likely to help to avoid the clogging up of the 999 system, lessen the growing work load of GPs and reduce pressures on hard-working accident and emergency departments. If that potential is realised, it will enable the ambulance trust to concentrate on the more serious calls and thus improve response times.
It will be a challenge for the trust to achieve the new ambulance response standard, which requires that from 2000–01, 75 per cent. of category A—life-threatening—999 calls must be responded to within eight minutes. The trust has commissioned an independent review of the service from Operational Research in Health, in agreement with health authorities in Devon and Somerset. The report will review the current use of resources and establish the base line for achieving the new performance targets by 2000–01. It will then be for health authorities to develop plans to meet the targets and to ensure that the new standards for ambulance response times are met.
The hon. Member for South-East Cornwall called for additional Government funding for the health authorities in the west country. He said that he believed that the process whereby money is allocated to individual health authorities does not take into account the cost of providing health services in a rural area, particularly given the geography of the south-west peninsula.
I shall, therefore, say a few words about the way in which health authority money is allocated. I remind the House that the background to this is the investment in the health service of £21 billion over the comprehensive spending review period—a sum substantially greater than that envisaged by the Liberal Democrats.
§ Mr. Denham
I will aim to give way if time allows, but first I must respond to a number of points.
361 The Department of Health uses a national weighted capitation formula as the basis for allocating hospital and community health services revenue to individual health authorities. The underlying principle of the formula is to distribute resources as equitably as possible, based on the health care needs of the residents of the various health authority areas.
Weighted capitation targets are not fixed in time, but are recalculated annually to determine each health authority's relative share of the overall resources that we make available to the NHS. Changes to the targets of individual health authorities are usually the result of routine updating to take advantage of the latest available data, such as population figures or boundary changes.
The weighted capitation formula has been reviewed. Last year we made four changes to it. The one most relevant to this debate was the introduction of a geographical cost adjustment for emergency ambulance services. That arose from an exercise to examine the effects of rural sparsity on the cost of providing certain services. Although a geographical cost difference was found for emergency ambulance services, no such difference was found in the cost of providing accident and emergency services in hospitals or patient transport services.
The resource allocation group recommended that we introduce an adjustment to reflect the costs of emergency ambulance services, which we have done. The new advisory committee on resource allocation has agreed that issues of rurality and cost should be part of its longer-term work programme.
The target figures that have come out of the formula are intended to provide a fair and equitable share of NHS resources for each health authority. It is important to point out that each of the health authorities that commissions ambulance services from the West Country Ambulance Services NHS trust currently receives more than its target allocation.
In 1999–2000, the hon. Gentleman's health authority, Cornwall and the Isles of Scilly, will receive nearly £6.5 million more than the formula would indicate is its fair share of NHS funding. Other health authorities in the region are in a similar position—North and East Devon will receive £5.4 million more than its target, Somerset more than £2.9 million, and South and West Devon an extra £7 million.
I am aware that Cornwall and the Isles of Scilly health authority, where the problems in achieving the response times are most marked, is faced with particular financial difficulties, and it will develop a financial strategy that addresses its deficit. To assist the health authority during the transitional period, I recently announced a £2 million grant for the coming year from the special assistance fund to that health authority.
The hon. Gentleman spoke of his concerns about a possible European Union directive requiring a change from two-stretcher ambulances to single-stretcher 362 vehicles. I believe that his worries have arisen out of the work being undertaken by the European committee for standardisation, which is trying to put in place standards that are similar across the European Union, to enable fairer competition. Hon. Members will be reassured to learn that no EU directive on ambulance specifications such as the hon. Gentleman describes has been signed. Hon. Members will also be pleased to hear that the current proposals on standards being examined by the committee relate to the space requirements in emergency ambulances and will allow two-stretcher ambulances to continue to be used.
There are sound clinical reasons why some ambulance trusts in England may want to consider the adoption of single-stretcher ambulances. For example, a single paramedic might find it difficult to treat two seriously injured patients adequately at the same time. Any decision to move to the use of single-stretcher vehicles will be for individual ambulance trusts to take in the light of best clinical advice.
I have been assured that if introduced, the changes being discussed will relate only to new vehicles. There will, therefore, be no need to renew entire ambulance fleets as a result of any forthcoming directive. I am also assured that old ambulances can continue to operate until the end of their operational life, so they could be sold on to organisations such as St. John Ambulance.
If the hon. Member for St. Ives (Mr. George) is still interested, I shall give way to him now.
§ Mr. George
I am grateful to the Minister. With reference to his remarks about screening emergency calls to the service, the problem in my constituency is lack of hardware, particularly for night cover. Will he comment on the number of ambulances available in rural areas, especially overnight, and the difficulty of meeting emergency response times? The target times could not be met without the support of the voluntary sector, especially the air ambulances.
§ Mr. Denham
That brings us back to a central point in the debate. There is a responsibility on the trust to work with the health authorities to achieve the necessary response times. Block capital is allocated to all NHS trusts according to a set formula. The West Country Ambulance Services NHS trust receives its allocations in the same way as all other ambulance trusts. The trust bought 17 new vehicles in 1998, plans to purchase nine in the coming year and hopes to purchase 14 new vehicles in 2000.
I remind hon. Members that the Government have provided real-terms increases in funding to all health authorities in the south-west for the coming year. It is the responsibility of the health authorities and the ambulance services trust to work together to ensure that the trust can improve response times and provide better care for patients.