Mersey Ambulance Service (Hansard, 26 November 2003)

§ Helen Jones (Warrington, North) (Lab):
I rise to express my deep concern about what is happening inside the Mersey regional ambulance service—a concern that is shared by several other hon. Members, particularly my hon. Friends the Members for St. Helens, North (Mr. Watts) and for Knowsley, North and Sefton. East (Mr. Howarth), who, along with me, have already written to the Minister about this issue.
Let me make it plain at the outset that this is not a debate about Government funding—in fact, the income base of the service has increased by 9.9 per cent. in a year, according to the most recent figures I have, and it is not underfunded for emergency care—nor is it a reflection on the front-line staff, for whom I have the greatest respect. Indeed, I agree with the Commission for Health Improvement's last report on the trust in which it said: The enthusiasm of ambulance crews to deliver an efficient service to the public is remarkable. It is very sad that that enthusiasm is not matched by an efficient management, for I have reached the conclusion that the trust has serious management problems that must be laid at the door of the chief executive and, ultimately, the strategic health authority, which has not taken the appropriate action when matters have been drawn to its attention.
Let us remember that it was a good trust. It was one of the first to meet the eight-minute targets for emergency responses in urban areas, for example. It is now a one-star trust, and the CHI report pointed out serious problems in its procedures and practices. For some time, hon. Members have received information from inside the trust about its management and the problems in its control room. This issue came to a head when my hon. Friend the Member for St. Helens, North and I received information that, over the weekend of 1 and 2 November, there had been serious shortfalls in ambulance provision in Warrington and St. Helens. We were not notified of that by the trust. When we started to make inquiries, the trust's response told us much about its management failings.
I tabled a question that was answered by the Parliamentary Under-Secretary of State for Health, my hon. Friend the Member for Welwyn Hatfield (Miss Johnson), on 17 November. That answer told me—I am sure that she answered in absolute good faith that the shortfalls were due to the closure of Warrington hospital to emergency admissions. May I caution Ministers to be very careful about the information that is relayed from the trust and the SHA? I have a copy of the trust's occurrence log for that weekend. The Department of Health tells me that that log is not available centrally, but may I tell it that, as almost every newspaper in my area has a copy, it ought to obtain one?
The log runs from 7.5 on 31 October to 5.45 on 3 November, and it shows an organisation in real crisis. Shortfalls in ambulance provision kept being reported all through that weekend, the first of which occurred at 10.17 on 31 October. Other shortfalls were recorded at 119 16.2, and again at 20.13 and 20.24. The same thing is apparent in the records for the next day, not just in Warrington and St. Helens, but throughout the area. People called in sick. Ambulances were single-staffed or unstaffed. That was long before Warrington hospital closed its doors to all but life-threatening emergencies, which did not happen and was not recorded in the log until 18.13 on 1 November. Although the sudden surge in emergency admissions throughout the area on that day certainly exacerbated problems for the ambulance service, it was not the cause of them.
Even more worrying is the way in which the trust deals with 999 calls. I asked a question about how many times the trust had been contacted by BT in the past six months to express its concern about the handling of 999 calls. In answer, I was told on 19 November that it was contacted once. If that is what the trust is telling the Department of Health, it is guilty of a gross deception, because the log clearly shows that, over that weekend, BT rang 10 times to complain about difficulties in putting through 999 calls. On one occasion, there was a delay of more than eight minutes, and on another, of nearly seven minutes. At 1.38 on 1 November, BT Newport rang the critical contact number to complain that it had a critical call that it had been unable to pass for 11 minutes. Merseyside police also rang that weekend to express their concerns that 999 ambulance calls were coming through to them, presumably because BT could not get them answered in the ambulance control room.
The trust's response is to say that it was an exceptional weekend. Sadly, that is not the case. I have an email that was sent to Mr. Jackson, the director of critical care at the trust, on 7 October. It comes from Mr. Ian Hall, who is 999 liaison manager at BT. It makes it clear that BT has been in contact with the trust for some months—and most of us would regard that as more than once—over the trust's failure to deal with 999 calls in a timely manner and without undue delay". He says in the email that there has been little improvement despite that contact, and he points out some of the delays. He says that BT operators are being put in "an almost impossible position" because of the delays, which he calls "potentially life threatening".
Mr. Hall also gives some interesting figures. It appears that among 999 calls in August, 195 were not answered within two minutes. By September, the figure had gone up to 236, and the latest parliamentary answer that I have gave the figure for October as 332. The situation is getting worse, not better. Mr. Hall's email also reflects the fact that what we saw in the log for 1 and 2 November has been happening at other times in this trust. Delays of seven and eight minutes are reported. On one occasion, when a call was not answered until seven minutes had passed, BT rang the critical contact number and was told that there was only one person in Mersey regional ambulance service available to take calls. On another occasion, when BT tried the three numbers available to it and a call was not answered after 11 minutes, it rang again and was told that the control room was very short-staffed and would be all night. It asked whether it could put through calls to a neighbouring trust, but that request was denied.
120 I ask my hon. Friend the Minister to investigate why that request was denied, because surely the point of an ambulance service is to get ambulances to the sick people who need them. The point is not for a trust to defend its own bailiwick. If this had been going on for months and was not being remedied despite BT's contact, we have to ask what on earth was happening.
Mr. Jackson's response to the email was to say that he would discuss it with his executive colleagues as a matter of urgency. Whatever action they took was clearly ineffective, because the problems were still occurring into November. I suggest to my hon. Friend the Minister that they will continue to occur until there are changes in the management of the trust.
The CHI report made it very clear that many staff in the trust feel devalued and vulnerable because of the way in which changes are being introduced, and it pointed to poor morale in the trust. Sadly, there is no evidence that the problems have been addressed since the report was produced. Members constantly receive reports of increased stress on staff leading to increased sickness absence. There are poor industrial relations and the number of grievances lodged is a cause for great concern. The report recorded 153 grievances lodged between April 1999 and March 2002, and a parliamentary answer given to me says that there have been 66 since then. All that speaks of a trust in which the management are not able to tackle the problems that face them, industrial relations are poor, and they are unable to manage change effectively.
What is happening in the control room is a good example. I am told that there were recently only five staff on duty there instead of 15. The number later rose to seven or eight. In response, the chief executive was quoted in one of our local newspapers as saying that the trust could not magic people up to answer calls. Of course not, but one would expect that any trust that had such a problem would be looking at the causes of the absences and doing something to tackle it. There is no evidence that that is taking place. I also ask my hon. Friend the Minister to consider seriously why two managers were moved out of the control room—as I understand it, one was moved out to do project work, while the other went on secondment—with the funding following them. What kind of system of priorities is operating in a management when a control room is short-staffed, but people and funding are taken away from it, rather than put in?
I suggest that what we are seeing is the result of a particular management style, and particularly that of the current chief executive. I think that she has shown herself to be unable to accept any form of collegiality or to respond to criticism. Let me give one example. Shortly after her appointment, the chief executive decided to reorganise the management structure. She did so without any reference to the salary and appointments committee whose remit is to review and endorse such changes. When the committee reviewed the matter, she said that the chairman and non-executive directors were acting inappropriately. Despite the fact that an internal review of the trust concluded that they had acted perfectly appropriately, and the endorsement of that conclusion by the trust's solicitors, a highly respected local firm that has acted for many parts of the health service for a good number of years, she refused to accept the conclusion. I understand that, when mentoring was offered, she turned it down.
121 That is a style of management that not only destroys personal relationships but has led to the introduction of procedures in an unsafe way. For example, call stacking was introduced in the control room. That is not a bad procedure in itself, but the way in which it was introduced led a manager to send an email to the director of performance saying that it was unsafe because no written protocols were in place. Instead of being treated as the whistleblowing email that it clearly was, that communication was reported to the chief executive, who promptly called in the manager and moved him from his post. What are we to make of a trust that deals with concerns about patient safety in such a cavalier fashion?
Unsurprisingly, a grievance was then lodged. During the hearing of the grievance, it emerged that another procedure, "treat and refer", had also been introduced in a very odd way. Again, there are arguments for using treat and refer, which can be a very useful procedure, but it requires proper training for paramedics and clear written protocols. The procedure was being trialled in the trust by a small group of paramedics. The chief executive unilaterally ended that trial and rolled out the procedure across the trust. I understand that there was no consultation with either the medical director or the director of clinical care, no written protocols were in place and the trust board did not approve the procedure prior to its introduction. What we have to remember is that there are patients on the receiving end of these procedures, and their safety should be the prime concern. The trust's solicitors advised that by taking such action the trust had laid itself open to an increased risk of litigation. I find that a cause for deep concern.
I also find cause for concern when I hear about what happened at the end of the grievance procedure. I understand that, before the result was announced, the papers once again passed to the trust's solicitors. They advised not only that the grievance should be upheld but that there was a prima facie case of gross misconduct against the chief executive. That was, as I understand it, never investigated. It should have rung alarm bells at the strategic health authority because I am told that its chairman had been notified of the problems with the management structure early on, and both the chairman and the chief executive were made aware of the grievance procedure's outcome and the advice of the trust's solicitors. One might have expected them to support the trust's non-executive directors when they decided—I believe properly—to call in an independent person to review what had happened with a view to possible disciplinary action against the chief executive. However, they did not do that.
The control room is in crisis, procedures are introduced without the proper protocols being in place and the solicitors are advising that a prima facie case of gross misconduct requires investigation. Instead, the chairman and chief executive of the health authority tell the trust board that it should get someone in to do what they call "board development work." If I had a suspicious nature, I would assume that they were trying to protect their friends. That is what happened'. The trust brought in a lady called Pearl Brown to undertake what was effectively consultancy work. She was taken on, because there was a vacancy in the trust, through a firm that provides interim executives at £1,000 a day. Yet the chief executive constantly tells the press that the trust does not have enough money.
122 The board gave Pearl Brown a fairly wide remit. but I understand that most of her work focused on the relationship between the chairman and the chief executive. Nevertheless, I am told that her report concludes that the management of the trust is dysfunctional. It is not simply dysfunctional but a disaster for the front-line staff and for the patients on the receiving end. That cannot be allowed to continue.
I ask my hon. Friend the Minister to examine those points carefully. I strongly suggest that there should be a review of what happens in the trust. It should involve outside people, possibly someone who has experience in ambulance services and someone with experience in industrial relations, which are clearly disastrous there. She should examine the role that the SHA played. Did the chairman and chief executive consult their board before advising the trust? If so, what information was given and on what basis did they decide to disregard the trust's solicitors' advice, which would have been properly investigated if it applied to another employee? I make no comment on the potential outcome, but the advice would have been investigated. Those matters should be considered urgently before the words "potentially life-threatening situation" become simply "life-threatening situation". Our constituents deserve better.

§ The Minister of State, Department of Health (Ms Rosie Winterton)
I congratulate my hon. Friend the Member for Warrington, North (Helen Jones) on securing the debate, which reflects her long-standing interest in health provision in her local community. I know that she has expressed the views of other hon. Friends in the area.
As my hon. Friend knows, I visited the Mersey regional ambulance service recently and, like her, I was impressed by meeting some of the front-line staff who are clearly dedicated and enthusiastic about participating in some of the new ways of working. Mersey regional ambulance service was the first regional ambulance services to be created in the United Kingdom and one of the first to undergo a review by the Commission for Health Improvement. That took place in October 2002, and the trust gained one-star status in 2002 and again in 2003.
Since the CHI review, the trust agreed and published in March a comprehensive action plan that spans two years and deals with the comments and recommendations in the report. Not only the trust board but the strategic health authority monitors progress.
As for the organisational development of the trust, the roles and responsibilities of the executive directors have changed in the last financial year to improve management performance throughout the organisation. The trust has also been refocused, covering seven areas rather than three to reflect changes in the NHS and the local health community. A locality manager has been appointed in each area, which has improved clinical supervision.
My hon. Friend mentioned concerns about the trust's performance. I certainly know of occasions on which the 75 per cent. target for category A life-threatening calls has not been met. In August, for example, the figure was 123 72.9 per cent. There was, however, a significant increase in the number of 999 calls during that month, mostly owing to the heat wave. The increase in activity is a general trend experienced by the trust. Between April and November 2002, the number of 999 calls was 120,576. During that period in 2003, the number increased by 8,174, or 6.7 per cent.
Like other one and two-star NHS trusts in the Cheshire and Merseyside strategic health authority, as part of the local health economy's commissioning plan, this month the Mersey regional ambulance service submitted an action plan to the central commissioning group representing the 15 primary care trusts in Cheshire and Merseyside. The individual action plans formed a part of a process to improve overall performance. The trust and the commissioning group continue to work together to establish whether any further action is needed to ensure that the trust meets an 80 per cent. target from April 2004. Last month, the 75 per cent. target was exceeded, with a figure of 79.23 per cent.
My hon. Friend referred to events that took place over the weekend of 1 and 2 November. Between 6.45 pm on Saturday and 8 pm on Sunday, Warrington hospital's accident and emergency department was forced to divert blue-light ambulance admissions. The temporary diversion from the hospital put pressure on other hospitals, and on the ambulance service. The impact on other hospitals was relatively minor, but the effect on the ambulance service was much more obvious.
Ambulances were diverted on occasion as far afield as Stoke and Manchester, outside the Cheshire and Merseyside area. The diversion meant that ambulances took longer to return to the area and respond to other calls, which had an adverse effect on the performance of the ambulance service. Moreover, the number of calls received over that weekend was much greater than usual: there were approximately 500 extra calls.
My hon. Friend is obviously concerned about the process of dealing with emergency calls. As she said, 999 calls are initially routed through British Telecom, whose performance target is the answering of 95 per cent. of calls within five seconds. Those calls are then passed to the appropriate emergency service.
If BT experiences a consistent delay in the answer of calls, it will contact the service to check whether there is a problem. Over the weekend that we are referring to, the trust received calls from BT to check their status. However, even though those calls were received, it was not necessary for BT to divert calls for Mersey regional ambulance service to other ambulance services. I take on board the points that my hon. Friend made about the log, and perhaps we can come back to that if we can have further information from her on that particular issue.
In terms of BT having difficulties in contacting the trust, which resulted in e-mail correspondence, I know that the e-mail my hon. Friend referred to was received by the trust in October. That is the only formal contact in the last six months, and a BT liaison manager felt it necessary to raise with the trust the handling of its emergency calls. The purpose of the e-mail was obviously to arrange a meeting to discuss what improvements could be made.

§ Helen Jones
The e-mail says: Jim Elliott of my Newcastle team has been in regular contact… it names the people he has been in contact with— over the delay situation. That does not appear to me to be simply one contact. It says clearly that things had been going on for several months.

§ Ms Winterton
The contact to which I am referring would be what is considered a formal contact—that is, one requesting a meeting.
As we have said, there has been an increase in the number of calls. As a result, in mid-September the trust identified a number of measures that would concentrate investment on more staff, better systems and improved ways of working. There is a series of ways in which the trust is looking at that matter. In view of the time, I will not go over those individually, but, to give an example, in terms of recruiting more staff, the first 11 of 22 posts identified as being needed will start on 1 December. Also, a bank scheme is being considered to allow staff from elsewhere in the trust to take calls in the emergency control room.
In addition, a meeting between representatives of the trust and BT took place on 10 November at which emergency call handling and the trust's action plan were discussed. My hon. Friend knows that in our shifting the balance of power policy we give local people the power and resources to commission services that best meet the needs of the local population. It is the role of the strategic health authority to manage the national health service locally and to provide the link between the Department of Health and the NHS. However, I assure my hon. Friend that strategic health authority monitoring and support arrangements are also in place within the Department.
On where we go from here, I understand that a meeting has been arranged between local MPs, the Mersey regional ambulance service and the strategic health authority. I hope that its outcome will be clarity about the action plans that are in place to improve the trust's performance. However, I fully accept that my hon. Friend has raised a number of points tonight that she might wish to pursue further and the Under-Secretary of State for Health, my hon. Friend the Member for Welwyn Hatfield (Miss Johnson), will be more than happy to meet local MPs to discuss any further concerns that arise, perhaps following on from that meeting.
I hope that I have also been able to assure my hon. Friend the Member for Warrington, North that measures are in place to improve performance. On top of that, if she still feels that there are concerns that she wishes to raise, my hon. Friend the Under-Secretary, who has responsibility for public health, will be more than happy to sit down to discuss them to see whether further measures need to be taken.