The tradition and practice of the House has been to express grievances on the Adjournment. The Minister's closing remarks in the previous Adjournment debate do not accord with the traditions of this place. The Minister knows very well that when private Members raise Adjournment debates, whether it is the first, second or, as in this case, the third Adjournment, it is not the custom for Opposition Front Bench spokesmen to be present, nor is it the custom for other hon. Members, other than by arrangement, to be present to express their views. We have had not a formal debate on health, but a debate on the Adjournment in which individual hon. Members have excercised their right to raise particular items. It so happens that three of those items have been about health.My Adjournment debate relates to the out-patients ambulance service in London, or, perhaps more accurately, the non-emergency ambulance service in London. I hope to be typically robust because this Adjournment before grievance is not just for this week or this day, but is, in effect, the Adjournment before grievance for this Parliament. In the Minister's closing remarks in the previous debate she made the claim, often repeated, about the Health Service being safe in the hands of the Government. However, my speech will show that the Health Service is clearly not safe in their hands. It is true that the Minister and her hon. Friends reeled off a host of statistics in the last few minutes of the previous debate. They have used the usual public relations trick of semi-truths. In the same way, the Minister referred to the empty Benches on the Labour side and implied that we are not concerned about health. That is not the case, but such was the implication. Semi-truth is of course only a next door neighbour to an economy of the truth. I will seek to prove—I challenge the Minister to deny it—that my thesis and that of my hon. Friends about the Health Service is correct. Indeed the Minister has already accepted that. A written answer on 5 March 1987, column 679, showed that there had been a 41 per cent. reduction in the number of non-emergency cases carried by the London ambulance services between 1984–86. That is a shocking figure. The fact is that the administrative edict that brought about that savage reduction was not originally from Alexander Fleming house or from Health Ministers or the Department of Health and Social Security. It came from a Rayner-style edict from No. 10. That is a remarkable example of the elected dictatorship that is now on offer before the electorate. In an Adjournment debate on 31 October 1986 I showed how that reduction had come about. Since then I have received further figures and further answers from the Minister. I wish to draw the attention of the House to those answers to make this issue a major matter of grievance. On the occasion of that Adjournment debate the Minister—I am glad to see that she is present because she has to answer for these matters—admitted that some 10,500 fewer walking patients were being transported—a reduction of 44 per cent. The Minister said:
What greater expression of ministerial responsibility and approval can there be? On that occasion, by way of assurance, the Minister told us that the acute ambulance service, the vehicles that run through the streets with sirens sounding and lights flashing, were being protected. The Minister had said in an earlier debate that if someone suffered a heart attack at Waterloo they would be taken right to Barts. However, if one of my constituents has a heart attack in Newham, what chance is there that Newham hospital's accident department—opened less than two years ago by the Queen—will be open? That accident department has been closed twice since Christmas, once for 40 hours and once for 60 hours. Even if one is transported in an acute ambulance, one is not necessarily transported to the emergency department of a new hospital, manned and ready for action. There are some 350 acute ambulances in London and they travel some 3·5 million miles a year. There are 230 tail-lift non-emergency ambulances and some 400 so-called "coach" ambulances. They travel 7·5 million miles a year—twice as much as the acute ambulances. However, it was those non-emergency ambulances that were cut by 41 per cent. I am sure that the public are not aware of that reduction because the administration of the London ambulance service is arcane almost to the point of imbecility. It is run by the London ambulance services, quartered at Waterloo, and it used to be part of the Greater London council services for London. The ambulance service was transferred to the management of the South-West Thames regional health authority, which manages it on behalf of the four regional health authorities of London that meet in the centre of the city. The London ambulance service has, quite sensibly, four district organisations that relate to the district health authorities. Therefore, the chain of accountability to the House is complex almost to the point that the service is not easily accountable other than in a debate of this nature. As I explained in the previous Adjournment debate, several years ago, a gentleman from the East Birmingham health authority, Mr. Payne, was asked to make a survey on how non-emergency ambulance services could be provided more efficiently. One person, one study, but consider the results. In the course of that study Mr. Payne said that there was some misuse of the non-emergency ambulance service. I am prepared to believe that. However, when a non-emergency ambulance takes somebody to a hospital or a day centre that action must be certified by a medical person. As a taxpayer I am happy to give that medical person a little bit of leeway. Mr. Payne estimated that there was a 4 to 10 per cent. misuse of the service. He suggested that a possible saving of £9·4 million could be made. In London—the Minister is aware of this because she answered one of my questions on the matter—there is no evidence of such misuse, but the cuts went ahead."I am more than happy at that development."—[Official Report, 31 October 1986; Vol. 103, c. 666.]
Not now there isn't.
The Minister may say that, but I asked a question about previous misuse. If I am wrong, no doubt the Minister will correct me when she replies.Mr. Payne—I do not wish to single him out unreasonably as the civil servant responsible, but his name was given on the document—presented his paper to the Minister. The Minister agreed that the way to reduce the cost was to make each district health authority in some way accountable for the ambulance service it received. Monetarism or Marks and Spencerism may make sense in the retail business, but it was pushed on to the Health Service. During the debate on 31 October, in column 659, I quoted from the document that had been produced. I wish to do so again because it makes the case clearly. It states:
In other words, local health authorities were being given some sort of quota, in terms of mileage, or of financing, or the number of ambulances available. If they wanted to buy in more, they had to obtain them from the private sector. I shall be saying more about that anon, because the writing is clearly on the wall. The way to get the costs down was by tightening up the finances. I have no objection to that, provided that the level of services for the people who need them, and their cost effectiveness and efficiency, were maintained. However, I do not necessarily think that they have been. Last summer, as everyone involved in the service in London knows, there was chaos. A letter went out from the South-West Thames regional health authority asking district health authority chairmen to cut demand by 40 per cent. It was an appealing letter, which read like a charitable letter in reverse. So the service was reduced. The results for people such as those in Newham, which is the area with the fewest cars in south-east England, were catastrophic. Those people are the least able to get out on their own, and the least able to be driven by kind neighbours—not that the people in Newham are not kind, but they do not have the same number of cars as people elsewhere. The bus service there is now under threat, and chaos, hardship and heartache have ensued. One might say that such a threat was not intended; but its results were malign, vindictive and inhuman. The hon. Lady and the Government, who were responsible for them, may say that they did not know that that was going to be the result. However, anyone would know that a 40 per cent. cut, which was the aim, would result in those sorts of difficulties; and so it turned out. In a question that I asked on 6 November 1986—I shall read it because the hon. Lady disputed the point—I asked the Secretary of State:"It would he open to districts to buy in part of the service from other public agencies or the private sector if this was more cost-effective, providing the quality of the service was maintained."
Referring to my accusation, the hon. Lady said:"what evidence he has received, concerning alleged non-appropriate use of the non-emergency ambulance services in London; and by what percentage those calls have changed between 1984 and 1986."
It is clear that all this was not even based on Mr. Payne's call for a 9 to 10 per cent. reduction. It was quite baseless, apart from the desire to save money. And the Government say that the Health Service is safe in their hands. What were the actual reductions? The hon. Lady provided me with a table, published in Hansard at columns 679 to 682 on 5 March 1987. The reduction in non-emergency services between the years 1984 and 1986 was 41 per cent. in London. The figures were further broken down into four divisions of the London ambulance service. I asked about the quarterly and the annual reductions. It is ironic that the biggest reduction of all—45·5 per cent.—is in the north-west division, which covers the London borough of Barnet and the constituency of the Prime Minister. Let her go to her constituents and say, "The Health Service is safe in my hands." The hon. Lady's figures show a reduction in non-emergency ambulance services of 45 per cent. in the Prime Minister's area. Those are the facts—not the half truths that we heard in the hon. Lady's PR speech of a few minutes ago. I have challenged the hon. Lady to deny those facts. There is more: in addition to the out-patients who are carried and who are getting better, there are out-patients who are sick and need treatment—people who, perhaps, come out of hospital rather too soon and are taken back. Out-patients are not necessarily fit and well. In addition to such people, who are carried by the London ambulance service, the districts bring in other people by services which are not run by the LAS. These are the so-called indirect services. Old people are taken by minicabs, which are difficult to get into and out of. Minicab drivers may be sympathetic and willing, but they are not skilled That service is growing. An indirect service may be run by a contractor, too—that is being encouraged, and the increase in indirect services is quite startling. Of course, a relatively low figure is involved. It started with 212,000 miles in 1984 and increased to 346,000 miles in 1986—an increase of 63 per cent. So the public sector service in the Prime Minister's area has declined by 45 per cent., and the increase in indirect services in the whole of London has been one of 63 per cent.—services bought in from outside contractors. That is the trend. We know that the Government, if returned to office, will privatise as much as they can. Do they wish further to privatise the non-emergency ambulance services in London, as distinct from the acute services? They appear to want to do so, because they are increasingly separating personnel. How have the Government got away with this in the minds of the public? What about all those cancellations about which we heard? Last summer, there was chaos, and there were cancellations. In reply to questions that I have asked her, the hon. Lady has said that, in Newham hospital and in the Newham district health authority, there are now no cancellations worth mentioning. That, again, is a PR fact: we are all right; the Government say that the services are slightly increasing. I have made inquiries about that and I understand that, because there was so much chaos, the medical staff concerned said that they could not tolerate the situation. Out-patient lists were in chaos, and people were missing appointments. An old lady who had missed eight in a row wrote to me. So the authorities concerned understandably tightened up the criteria for those whom they certificated as being able to be called for by an ambulance. In other words, what they did—as you, Mr. Deputy Speaker, or I, or even the hon. Lady would have done—was say that, as the ambulances were not available, they would ensure some sort of continuity in the service. Consequently, they upped the limit, which is, to some extent, variable, as it is a matter of judgment. That is what I have been told has happened. Other matters, too, have been dealt with in the way that anyone with common sense would deal with them. A lady, for example, who comes in once a week might be asked to come in once a fortnight. The criteria of need and requirement have now been geared to different considerations. The administrative impact of this lack of flexibility has resulted in a change in the criteria. There has been a squeeze and, as a result, no doubt the costs have fallen, but the price has been paid in the quality of service that dedicated people can give to their patients. Another change has been the introduction into this important service of 200 part-time staff. The hon. Lady is nodding her agreement. Two hundred part-timers are now engaged in the London ambulance service and more may be recruited. I have been told—I do not have any figures to prove it—that it is possible for someone to do two part-time jobs: the economics are such that one starts early and takes people to the day centre or hospital, then has a long break, and then does a second part-time shift in the evening. This is a lowering of the standards of the staff, their expectations and their training. I have a number of questions to ask the Minister. First, is it the DHSS's intention as it is now constituted further to separate acute ambulance services from non-emergency services in London? The hon. Lady might not be able to give an undertaking tonight but she might be able to write a letter tomorrow or on Monday to that effect. Secondly, how is the availability of money for ambulances calculated for each district health authority? In other words, what is the base? Is the Payne memorandum, which came from Downing street and which might be softened to some extent, still the basis of policy for the DHSS? Thirdly, is it the Government's policy to permit the contracting out of ambulance services to small firms or individuals? On 6 May I asked the Secretary of State for Social Services"We have no information on alleged non-appropriate use of non-emergency ambulance transport."—[Official Report, 6 November 1986; Vol. 103, c. 598.]
The answer read:"what tests of competence or other conditions relating to standards of remuneration and safety arc applied by district or regional health authorities when using ambulance contractors for non-emergency ambulance services."
That is a recipe for undermining the proud standards of the London ambulance service. As Winston Churchill said in this Chamber, or rather its predecessor, the bad contractor drives out the good and the worst drives out the bad. How can we expect district health authorities, with all their problems, to monitor and apply standards of decent employment and decent standards of safety? That should be done by the London ambulance service as a whole, and that is what has been done. We are faced with a recipe for undermining the quality of the service and the London ambulance service itself. I ask the Minister to deny that that will be the result of that which is proposed. We know what is happening within the bus service—I shall not pursue this—and we know also what happened on Monday. We do not want that to happen to our ambulance service. Unfortunately, the Prime Minister, the Government generally and, self-admittedly, the Minister, are driving the London ambulance service in that direction. Does the Prime Minister care? On 2 April my hon Friend the Member for Tooting (Mr. Cox) asked the Prime Minister about hot beds—two patients and one bed—in Barts. There is one person in the bed while the other is up and out of it during the middle of the day. The Prime Minister said that the practice of day surgery was welcome and claimed that expenditure in London on the Health Service had increased under her Government. She may make that claim, but the expenditure on the London ambulance service has dropped. That has been determined by what she has brought out of No. 10 Downing street. It might be said that it is only the ambulance service that has been so affected, but both the staff and the customers—our citizens—have been undermined, demoralised and dismayed. This trend has been accompanied by a regrading of staff and a change in their terms and conditions of service. There has been a change in negotiating patterns and a reduction of public resources. There has been a threat of privatisation and in some services there has been an accompanying lack of public repute. Is it a coincidence that what has happened in the London ambulance service has been repeated to some extent in other public services such as schools, the DHSS, universities, polytechnics and sectors of the Civil Service and local government? The same formula has been applied time and again. There is an epitaph for this Administration that comes from the experience of the London ambulance service. If anything, we have a parable, but it is almost the reverse of that of the Good Samaritan. It is the obverse of what this Administration started with following a bizarre quotation on the steps of No. 10, but one which is well known. The example is the London ambulance service, but many other areas of the public service provide it because the same formula has been used. I give the Government an epitaph as they finish their administration. It is as follows: Where there was harmony, we have brought discord; where there was truth, we have brought error; where there was faith, we have induced doubt; where there was hope, we have brought despair. The case in respect of the London ambulance service is proven—it is clear that the service is unsafe in the Prime Minister's hands. If that is true of the London ambulance service, it is true, as I have tried to prove, of the Health Service and of the nation."Health authorities are responsible for the day-to-day management of National Health Service ambulance services. It is for them to arrange the most appropriate, efficient and cost-effective means of transport for each of the patients the ambulance service is asked to convey. This may involve the use of taxi, hire car or other private contractors as well as volunteers. Standards of safety and payment to private contractors are not set centrally: health authorities are responsible for negotiating contracts locally and for setting standards of service, patient care and safety."—[Official Report, 6 May 1987; Vol. 115, c. 429.]
I am grateful to the hon. Member for Newham, South (Mr. Spearing) for raising once again the issue of the London ambulance service.The new salary structure for ambulance men came into effect in March 1986 and it changed radically the pay arrangements for ambulance personnel. It provided an opportunity for all ambulance services to rid themselves of inefficient working practices. With the introduction of the new structure, the London ambulance service took steps to improve the front line—in other words, the emergency service that it provides. This meant that temporarily staff resources had to be transferred from non-emergency services to be redeployed on front-line work. The South West Thames regional health authority, which manages the London ambulance service on behalf of the four Thames regions, took immediate steps to increase recruitment within the non-emergency service to make up for the shortfall. The hon. Gentleman has referred to the number of part-time employees who have been taken on, and he was right when he spoke of about 200. Part-time employees were introduced into the service a year ago to try to enable the work force in as flexible a way as possible to cover the different and increasing demands made on the service. I see nothing wrong with that. Since March 1986 there has been a significant increase in the number of full-time ambulance staff employed. Almost every month last year about 30 recruits were undertaking training within the London ambulance service. There was a low turnover and the results have led to a substantial increase in staff. I believe that we are seeing the benefits of a sustained recruitment campaign, and I am sure that the hon Gentleman's concerns will be met in this way. I hope that he will accept that I shall scrutinise the Official Report and write to him on all the other issues which he has raised at very short notice this evening.
Before the Minister sits down——
I have sat down.
will she accept for the record that there was notice last week of this debate, which was given to the Minister for Health? I am grateful to the hon Lady for saying that she will write to me, but I am sorry that she will not answer my questions this evening.
Question put and agreed to.
Adjourned accordingly at two minutes to Eight o'clock.