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House of Commons Hansard
12 July 2017
Volume 627

    [Geraint Davies in the Chair]

  • I beg to move,

    That this House has considered ambulance services in Devon.

    It is a pleasure to serve under your chairmanship, Mr Davies. Let me say at the outset that we all pay tribute to our blue light services and that this debate is not in any way intended to criticise them. The intention is to set out the challenges that they confront and to celebrate their professionalism and the work that they do, but also to ask my hon. Friend the Minister to address some key issues that they face in Devon and, in particular, in my constituency.

    The debate has been triggered by a number of incidents. People have contacted me either directly or indirectly to raise concerns about long waiting times faced by my constituents; an incident that typifies the situation happened last month. An elderly lady was left for two hours at the roadside, on a baking hot day, waiting for a paramedic crew to arrive. She had serious neck injuries and was in some distress. Were it not for the kindness of passing strangers, things might have been even worse, but a consultant anaesthetist happened to be passing and was able to provide critical assistance at the scene, and the lady also had assistance from the police and from staff from South Hams Community Hospital. As a result, the outcome has been good, but it could have been very different. That has caused a great deal of concern, because it is not an isolated incident. Although much of the focus of my speech will understandably be on the critical, type 1 cases, which require a response within eight minutes—everyone understands that—I would like the Minister also to think about those other cases that we are all coming across in our constituencies which are not immediately life threatening but are nevertheless very serious and where the outcome can be very different unless we see a timely response from our ambulance services.

    First, I would like to address demand, which is rising at an extraordinary rate. During the five years to 2016-17, over the area of the South Western Ambulance Service NHS Foundation Trust we have seen a considerable rise in demand, but there has been a 19.2% increase in the Totnes constituency alone, a 29% increase in Plymouth and a 23.7% increase in Torbay. The challenge is far greater in a rural setting, for obvious reasons. The SWASFT area is the most rural area in England; and if we look at the activity for Devon, we see that 23.5% of SWASFT’s activity is in that county, but that is matched by only 22.2% of its funding.

  • I very much appreciate the debate that my hon. Friend has introduced in the Chamber today. She is making a very good point about the rurality of Devon, which is one of the largest counties in the country. Of course, the issue is not just its size. If one starts going north-south, there are no really fast roads—we need much more done to the north Devon link road. Apart from the scale of the county, however, the issue is about getting an ambulance to an incident in time and our very scattered population. My hon. Friend makes a very good point. I am sure that Ministers are aware of the size of Devon, but there is also the question of the time it takes to get from A to B if one is not going on major roads.

  • I thank my hon. Friend for his intervention. Of course, as we know, demand can escalate considerably during the peak summer times, but many of our roads are single-track ones with passing spaces, and it can be very difficult to get an ambulance resource to the scene in a timely manner.

    My first point to the Minister is that there are no concessions for rurality; there is no funding premium to allow SWASFT to meet the extra demands that it faces. In fact, overall, its funding has fallen by 2.46% per incident in 2017-18, compared with 2014-15. It has to meet the huge increase in demand with shrinking resource, in what is one of the most challenged areas in England because of rurality. I would like the Minister to acknowledge that key point and the impact of rurality on response times.

    My second point to the Minister is that although overall SWASFT is doing a good job in meeting the performance target of 75% of category 1 calls receiving a response within eight minutes, that does rather mask the picture in the most rural parts of the area. Let us take the South Devon and Torbay clinical commissioning group area as a whole, for which we have some data that show that it just meets the target, with the figure of 75.65% of calls. If we look at the breakdown for the Totnes constituency, we see that during the past three months the figure has been 61%, so my point to my hon. Friend is that, when considering a county such as Devon, he should look not just at the overall, top-line figure, but at the impact in the most rural parts of the constituencies. I hope that he will ask for that as an ongoing measure, as a response to this debate.

  • There is a specific example of exactly what is being described by my hon. Friend in my constituency of North Devon—the situation in Lynton and Lynmouth, the twin villages right on the north coast. At the beginning of last week, the South Western ambulance trust withdrew what was in effect a rapid-response paramedic vehicle that was traditionally stationed in Lynton and Lynmouth, specifically because of the rurality and the distance from anywhere else of those two villages. There is a lot of concern in the community because that service has been withdrawn. I pay tribute to the CCG, which is looking for an alternative arrangement, but the fear is that there is still a gap, and the response time, because of the distance of Lynton and Lynmouth from everywhere else, is key. May I ask my hon. Friend the Minister, through my hon. Friend the Member for Totnes (Dr Wollaston), to consider that particular example?

  • I thank my hon. Friend for that intervention. Likewise, very considerable concerns have been raised in my constituency about the withdrawal this month of rapid-response vehicles from Dartmouth and Kingsbridge and in Totnes. I understand the reasoning that double-crewed ambulances can provide the conveyance that people need to hospital and that utilisation of the single vehicles is less—about 24%. I understand the rationale behind it, but equally I ask the Minister to respond to precisely the concerns that my hon. Friend the Member for North Devon (Peter Heaton-Jones) has raised, because the worry in communities such as mine is that once the double-crewed ambulances are conveying a casualty to an urban centre, they tend not to come back again, whereas the rapid-response vehicles did. There is a genuine concern about how we will ensure that the double-crewed ambulances come back.

    As I have said, I welcome the increase in the double-crewed ambulance resource as the rapid-response vehicles come away, and I am aware of the data whereby efforts are being made to provide a reassuring response that actually the number of hours in total will increase. However, that change is just coming in this month, and I would like the Minister to assure the House today that he will look very closely at the data as they emerge over the next few months, to ensure that those vehicles are returning to the rural areas, because I fear that otherwise we will again see that SWASFT is meeting the overall, top-line target for the entire patch, but that will be at the expense of rural constituencies such as my own, where there will simply be a worsening of the response. We need to look at that very closely, and I would like the Minister to assure me that, following this debate, he will specifically ask SWASFT to ensure that there is a response available and it does not worsen in the rural parts of Devon.

    I would also like to address the matter of the workforce, which is an issue across the NHS as the Minister knows. Within our paramedic resource there is actually an 11% turnover of paramedic staff, in part because they are such a skilled and valued workforce, which means in many cases they are being attracted into other parts of the NHS, for example to work in casualty departments and minor injuries units. Everyone can understand that, but we need to make sure that we are recruiting and retaining within our blue light response services as well. For example, there are currently about 100 vacancies over the whole of the SWASFT area, and 16 whole time equivalent vacancies in Devon alone. What is the Minister doing to work alongside Health Education England to address the workforce issues? I will again make the point I have done in previous debates about the impact of the pay cap on the recruitment, retention and morale of the workforce. Again, I call on Ministers to consider giving the pay review bodies greater flexibility to be able to increase the rates of pay.

    We know that there are pressures on our ambulance services, but we cannot view them in isolation. I would like the Minister to consider the impact that this is having on our other blue light services, particularly the police. They have raised some worrying concerns with me about not only the amount of time that they are having to spend on scene—as they did the other day in the incident that I described—while they wait for an ambulance resource to arrive, but the fact that on occasion they themselves have to take people to hospital who should really be conveyed by an ambulance resource. To clarify, in May this year there were 226 incidents where an ambulance was requested but no ambulances were available to be assigned in the Devon and Cornwall police area, and in June there were 158. These long waits are having a knock-on on the police’s ability to carry out their other duties, and that should concern us all.

  • I thank my hon. Friend and neighbour for giving way and congratulate her on securing this much needed debate. As she will be aware, it is not only the police who are experiencing long waits. One of my constituents, Susannah Tandy, has got in touch about an incident a week ago when her 12-year-old son fell 11 foot from a tree. An ambulance was called at 1 pm but did not arrive until about quarter to 4. These sorts of waits not only build up anxiety but could see situations get much worse. Thankfully Murphy appears to be making a recovery, but it could have been a lot worse.

  • I think we are all glad to hear that Murphy is making a good recovery. As my hon. Friend says, we must focus not just on the immediately life-threatening incidents but on the kinds of incidents that he described, where an ambulance is very important and somebody’s condition could deteriorate because of a long wait. For SWASFT we must keep an eye on not just the category 1 incidents, but the others as well, and I hope the Minister will do so.

    In this debate we should also celebrate the successes, because there are undoubtedly those as well. We have seen examples of very good co-working between our blue light services. For example, in the “collapsed behind closed doors” scheme fire services co-operate with the ambulance service where there are concerns that somebody might be collapsed in a residence. In the past the police may have responded, but now the fire service can also provide that assistance, and I pay tribute to those co-responders in the fire service. From my time as a rural GP in Chagford, I remember the number of occasions when people phoned me in surprise because the fire service had arrived instead of the ambulance service, but it is actually providing a fantastic resource. On occasions when it is absolutely critical that somebody has a defibrillator on site as soon as possible, the fire service can and does perform an amazing job. We have got further to go, particularly in remote rural communities where a fire resource might be closer to hand. I hope the Minister will look at how we can go further to make sure that we develop a multi-skilled workforce who are properly rewarded for the expertise and skills that they develop across the fire service.

  • The ambulance crews across Devon do a fantastic job. I represent an urban seat in Plymouth, but the demand that is placed on both urban and rural ambulance services has a knock-on effect, because there is no wall that divides Plymouth from the rest of Devon. Demand needs to be understood between both urban and rural areas. Will the hon. Lady comment on what happens in the summer months when the south-west becomes an even more popular tourist destination and additional demand is placed on not only the ambulance services but our wider emergency services? That moves the ambulance resources out of their normal patterns. Ambulances are increasingly moved to further away places with longer response times than their normal patterns might take them.

  • The hon. Gentleman makes an extremely important point. He will know that for both our ambulance services and our police services those kinds of influxes from outside are not adequately reflected in the funding formula. That is in addition to the rurality that he referred to. In fact, the key point remains that the greater danger is to people living in rural areas where, for example, a resource might take somebody to Derriford Hospital but not return, and then when the ambulance service dispatches the nearest ambulance it will be in Derriford. That is why ambulance services tend to get tied up.

    I would briefly like to mention the impact of the 111 service. SWASFT is doing extremely well—it is, in fact, the best-performing in the country—at treating patients at home rather than conveying them to hospital. That is the so-called “see and treat” model, and they are also doing well with “hear and treat”. However, there is a concern about the increase in calls, because there has been an overall increase in calls of 24% for the whole of the SWASFT area over five years, with 470 more calls per day, although only an additional 81 people per day are having to go to hospital. While that may reflect the great success of paramedics’ expertise in seeing and treating at home, will the Minister consider whether it also reflects unnecessary calls and the impact of 111, which has been raised many times in this House? Are too many people still having an ambulance called on their behalf when it could have been avoided?

    Finally, I would like to end on a positive note in thanking all our volunteers who do so much to save lives across Devon, working alongside our blue light services. I would like to praise all those who support our Devon air ambulance service, all the volunteer community first responders and those who support, fund and supply defibrillators in our communities. On behalf of all in this House, we thank them and our wonderful paramedics and ambulance service crews.

  • It is a pleasure to serve under your chairmanship, Mr Davies. I wish you every success in your endeavours elsewhere today. On that note, I congratulate my hon. Friend the Member for Totnes (Dr Wollaston) on securing not only this debate but unopposed re-election to the Chair of the Select Committee on Health, which role I am delighted to see her continue in.

    By happy coincidence, I had the pleasure of visiting the South Western Ambulance Service NHS Foundation Trust only last week. Having visited the chief executive in his office, and seen for myself some of the challenges presented by the rurality and the distances—as mentioned by hon. Members in this debate—I feel slightly better briefed than I would otherwise have been. I drove from Exeter to Barnstaple to Plymouth on the same day, in the height of summer, on a Friday, when the roads were, it is fair to say, not at their least busy. I do absolutely appreciate some of the challenges reflected in this debate that are imposed on the ambulance service’s ability to deliver the service to residents in this large, very rural and very beautiful county. It is particularly appropriate therefore that we have the chance to discuss this briefly this afternoon.

    I thank my hon. Friend for the characteristically considerate and appropriate way she posed challenges to me and thanked people employed in the ambulance service, and those who support it as volunteers, for the magnificent work that they do. She began her speech by recognising that the ambulance service in the south-west, like all other ambulance services in the country, is busier than ever. Demand has been rising significantly. Across the country, there were some 7 million face-to-face responses from the ambulance service in the year ending 31 March—a 14% increase over the last five years. In the south-west of England, demand has increased even more sharply, with a 29% increase over five years; I think she mentioned a 19% increase in her area of south Devon.

    The trust is challenged by the geography of the area it serves, with its greater distances and slower transport routes. Nevertheless, it is doing well, not just in meeting national targets but in comparison with other trusts. We should congratulate all those involved, but that does not mean that there are not a number of challenges. My hon. Friend the Member for Totnes mentioned a particularly difficult case in which an elderly lady was left waiting for some time, and my hon. Friend the Member for Torbay (Kevin Foster) raised a case from his constituency in which a child had to wait some time for an ambulance.

    This is clearly an operational issue. I strongly encourage hon. Members who are concerned about individual cases to bring them to the attention of the chief executive of the relevant trust, and to continue to represent to their constituents that even if the overall number of such incidents is not great, the ambulance service is required to provide an appropriate response through the disposition of its resources. From experience in my own area, I know that MPs are listened to by chief executives of ambulance trusts and can make a difference in securing deployment of resource to meet the particular demands and concerns of their constituents. It is well worth pursuing that approach.

    Let me touch on some of the initiatives under way to meet the challenges that we all recognise and that have been referred to in the debate. Sir Bruce Keogh undertook a review of the NHS urgent and emergency care system, which is trying to cope with the root causes of demand. Following the review’s recommendations, ambulance services will increasingly be transformed into mobile treatment centres, with greater use of “hear and treat”, in which telephone calls are closed with advice, and “see and treat”, in which paramedics are equipped to treat patients on the scene without a conveyance. There will also be greater integration with the rest of the health system. Some 2,600 more paramedics are now operating within our ambulance services across the country than in 2010, and in the past year 1,400 trainees have started on paramedic courses. There has been a big shift towards training more ambulance staff to undertake treatment on the ground.

    The Care Quality Commission has recognised that SWASFT is one of the highest-performing trusts in England, particularly in its “hear and treat” service, which enables clinicians to assess and triage patients over the phone and close the call without the need to send an ambulance. In April, 49.1% of calls to SWASFT were resolved without transportation to A&E—the highest percentage of any trust in England. That allows more patients to be treated in their own home or in the community without needing to be taken to hospital, helping not only the patient, but the system.

    Another way in which SWASFT is addressing the growing demand for services and the need to better manage peaks of activity is through reviewing how emergency vehicles and staff are rostered. Its review has moved ambulance resources closer to areas of high public demand. Instead of a paramedic crew logging on for a shift at a rural station and then getting pulled into an urban area—an issue highlighted by my hon. Friend the Member for Totnes as a particular challenge in her constituency—resources should now be positioned in the right places and should stay more local, more of the time. She expressed a degree of scepticism about whether that is actually happening. I can confirm that in my area in the west midlands, we have worked with the ambulance service to ensure that ambulance stations are not necessarily kept in the same physical location, but are placed in parts of the country where demand is highest. This can now be well mapped by ambulance systems to ensure that service is provided as close to areas of demand as possible.

    Evidence from the trust’s rota review shows that the patients with the most serious, time-critical and life-threatening injuries have experienced improvements in response times, and that ambulance resources stay local more of the time. My hon. Friend makes a perfectly reasonable challenge for that to be proven—for the facts that demonstrate it to be provided to Members of Parliament and the public—and I will encourage the trust to provide that information.

    My hon. Friend and other hon. Members referred to the trust’s fleet. It is being reviewed to enable the right resource to be sent the first time. The trust has invested £3.6 million, which has allowed an additional 61 double-crewed ambulances—an increase of 20%—across the operational area, meaning that in South Devon four more double-crewed ambulances will be available this year than last year. This approach has allowed a reduction in rapid response vehicles, which—as my hon. Friend said—are not being utilised as fully as the ambulance crews themselves and are therefore not always the best resource to send.

    There are now some 57 fewer rapid response vehicles. My hon. Friend the Member for North Devon (Peter Heaton-Jones) highlighted some areas in which that has caused local concern. I would say to him that the ambulance service needs to demonstrate to local people that fully crewed paramedic-staffed ambulances are now more readily available to serve communities, so that the people in most need of conveyance to hospital are more likely to get there more quickly. The trust needs to demonstrate that as it moves its resources to this new pattern.

    My hon. Friend the Member for Totnes is aware of the ongoing review of the way in which ambulance services respond to calls through the ambulance response programme. SWASFT has been involved in piloting new operating models. The new programme seeks to deliver clinically appropriate responses to all patients and is part of ensuring that the ambulance service in England remains sustainable. The evidence behind the ARP is extensive, covering data collected from more than 14 million emergency 999 calls. The review has looked at a number of key issues for the south-west, including the provision of ambulance services in rural areas and putting an end to unacceptably long waits by removing the long tail of ambulance response times.

    A revised operating model is crucial to achieving sustainability in the ambulance service, given the growing demand that we have all described. Trials have been independently evaluated, and the Secretary of State has recently received recommendations from NHS England. I hope to report to the House the ARP’s findings and NHS England’s recommendations shortly.

    In addition, SWASFT has adopted a number of recommendations to improve response times, particularly in rural areas. One such initiative, which my hon. Friend referred to, is the increasing use of community first responder groups across the south-west. Totnes is one of the focuses for the next phase of recruitment in South Devon, which will start later this month. There are some 458 community first responders and a further 110 fire co-responders across the county, alongside the network of public access defibrillators that she mentioned. SWASFT is in discussions with three of its local fire services about introducing a conveyance and support service by fire crews, which would help to supplement conveyance when ambulances are not available. These initiatives do not change the priority or category of a 999 call, but they help to ensure that a patient with a life-threatening emergency can begin to receive the required care as soon as possible.

    My hon. Friend rightly raised staffing. I understand that the clinical vacancy rate at the trust is currently 7.7%. The trust has undertaken a very successful graduate recruitment campaign, which has resulted in 130 graduates accepting offers to join it. They are expected to start in September, including 31 who will start in the west division, which covers Devon.

    Motion lapsed (Standing Order No. 10(6)).