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London Ambulance Service

Volume 124: debated on Tuesday 8 December 1987

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4.56 am

I am glad to follow the last debate on the National Health Service as a whole by initiating a debate on the London ambulance service, although this is a debate that should not be necessary. First, one would expect any ambulance service in the United Kingdom to be conducted in such a way that a debate in public on its efficiency and proper funding would be unnecessary. Secondly, any Government's view of this public service should be so high that criticism or controversy of the sort which I am afraid I must initiate tonight should be unnecessary.

This debate, as with the previous debate, is about resources. Ideally, I suppose, ambulance services, being domiciliary and local, should be a matter not for Parliament but for some form of local government. Indeed, until not long ago in London that was the case, coming as they did under the LCC for many years and, later, the GLC, which the Government have dissolved.

Somewhere in the Consolidated Fund there is an amount for the London ambulance service, because as from April of this year that service became directly funded by the Department of Health and Social Security and not by a levy on the four regional hospital authorities which constitute the London area, and I shall conclude my remarks by discussing the budget.

This is not the first debate on this topic in this House. On 15 May 1986 the hon. Member for Ravensbourne (Mr. Hunt) raised this issue from the Government Benches. I have had two Adjournment debates on it—on 3 October 1986, beginning at column 258 of the Official Report for that date, and on 14 May 1987, beginning at column 477. Both dealt primarily with the non-emergency service, which was put into a state of disruption, particularly in the summer of 1986, and I raised the matter of the so-called "walking cases" with the Minister.

We have had major differences of opinion on these issues, and I now believe, as a result of subsequent correspondence and parliamentary answers, that we have a major disagreement about some of the facts. I shall probe these matters tonight because there might be a prima facie case of maladministration. 1 do not want to say that that is so until I have given the Minister a chance to reply tonight, and subsequently in writing if she wishes to do so. I appreciate—although I do not apologise for bringing her here at this hour to answer the debate— that she may wish to reflect on some of the points I shall make.

It is unfortunately necessary for me to raise other topics, including that of the emergency service in 1987 and particularly from the spring of this year. Then I shall look at the so-called ORCON standards and the relationship of that to London. My next subject will be equipment and the control of the London ambulance service, and finally I shall return to the important matter of finance and the budget because here is one service, the emergency service, which nobody would deny must be demand led. That is a very unusual service for any Government to provide, especially for this Government.

I want to begin with the question of the non-emergency service. I revert to the debate on 31 October 1986 when the Under-Secretary of State for Health and Social Security said:
"A report in The Guardian of 27 October confirms some of the events. It says that the London Ambulance Service is carrying 30 per cent. fewer non-emergency patients today than it was two years ago. It says that only 27,500 patient journeys per week were being made this year compared with 39,500 in 1984. About 10,500 fewer walking patients were being transported—a reduction of 44 per cent. I am more than happy at that development." —[Official Report, 31 October 1986; Vol. 103, c. 666.]
Walking patients are those who do not have to be carried on stretchers or by wheelchairs, but are certified by a medical authority as requiring ambulances to take them to out-patient departments at hospitals. I challenged the whole basis of that with the Minister on 31 October. I said that the matter had arisen as the result of a Rayner-type scrutiny which had no proper basis in fact.

On 6 November 1986 I asked the Secretary of State for Social Services:
"what studies he has made and 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.

No formal studies have been made, as far as I am aware. The London ambulance service has drawn district health authorities' attention to the criteria set out in HC 78 (45) which states … we have no information on alleged non-appropriate use of non-emergency ambulance transport"—[Official Report, 6 November 1986; Vol. 103, c. 598.]

That was the Minister's justification for the massive cut of 44 per cent. which affected many people in east London. Elderly ladies wrote to me saying that they had had no fewer than eight out-patient appointments cancelled during 1986 because the non-emergency ambulances did not arrive.

I have no sympathy whatever for the Minister having to reply to two debates tonight—[Laughter.] This is no laughing matter. The Minister is laughing, yet the amount of disruption and dismay that she has caused in my constituency alone as a result of this hard-hearted, hard-boiled attitude is almost unbelievable. I fight with words here, Madam Deputy Speaker. I have no sympathy with the Minister for being here, but I have some sympathy with her because she laughs at such a serious and important matter.

The Parliamentary Under-Secretary of State for Health and Social Security
(Mrs. Edwina Currie)

I am laughing at the hon. Gentleman.

I do not mind if the Minister laughs at me, but she dare not laugh at my constituents.

I am glad to hear that.

In a letter to me on 26 June 1987, after the second debate on these matters, the Minister wrote in response to my claim that the massive cut was a result of the Rayner Studies. She said:
"With such a vast organisation as the National Health Service there are inevitably areas which can be managed more effectively. This is why Norman Fowler established a series of scrutinies on similar lines to the programme Lord Rayner had introduced in Whitehall. The scrutinies were designed to look at areas in which services to the public and value for money could be improved."
Fine; we would all go along with that. The Minister continued:
"Therefore, as you will appreciate, the scrutiny of the non-emergency ambulance service you referred to was initiated by this Department. The scrutiny suggested that there was misuse of the service."
That is directly contrary to the written answer that the Minister gave me on 6 November 1986. Either there was evidence of misuse or there was not. I notice the words
"The scrutiny suggested that there was misuse of the service".
I have yet to see that evidence, and I ask the Minister to produce the evidence now or later.

During the debate I also asked how regional hospital authorities check on the private contractors employed to take up some of the demand that the London ambulance service was prevented from meeting. In an answer dated 6 May 1987, the Minister said:
"Health authorities are responsible for 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 payments 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 have no doubt that taxi drivers and mini-cab drivers are good-hearted people, but they are not trained to provide the service for which at one time the non-emergency service of the London ambulance service was responsible. Even if the Minister turns out to be right and there is some evidence of misuse, it is quite wrong not to lay down central standards for the use of private contractors, particularly when sick people have to be taken to outpatient departments, as they must be if they are to recover and regain their health.

The second area I outlined was emergency services. Unfortunately, the emergency services are now in trouble, despite what the Minister said in the debate on 14 May 1987:
"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."—[Official Report, 14 May 1987; Vol. 116, c. 482.]
The hon. Lady was saying that we had to change the standard of the non-emergency services to keep the front-line service going, but in the early part of this year the front-line service was not kept going.

We now have difficulties with the emergency service — arguments and allegations have been made about shortages of vehicles. In the debate from which I have just quoted, I said that I had received evidence that since April of this year the DHSS had cash-capped the ambulance service, and the managers, in order to keep within the cash cap, had cut the budgets from the top, so that all managers of ambulance services were told how much overtime could be worked in their stations. Ambulance men were standing by at home, not able to go out, when vehicles were available.

There was much argument about that, and the Minister may wish to contest the facts, but it is clear from her letter to me of 8 September 1987 that there had been difficulties. She challenged some of the facts I had given, and she may have been right in making some corrections. Her letter said:
"Officials have looked into the articles you enclosed in your letter"—
I had enclosed numerous press articles—
"and they inform me that, for example, during the 24 hour period mentioned for 29 May 58 vehicles and not 52 were single manned for some period; of these 30 were single manned for one hour or less; 11 for one hour, but less than two; two for more than two hours, but less than three and three were single manned for less than five hours".
The figures may have been marginally wrong, but for that number of ambulances to be single-manned at that time shows that there was something wrong. We know that, since that time, there have been arguments within the service, which is not noted for its lack of concern for the public. No ambulance man will do things against the public interest without good reason, otherwise he would not, I am sure, be accepted for the service.

In a written answer on 10 July 1987 the Minister again said:
"No emergency ambulance shifts were lost due to constraints of finance"—[Official Report, 10 July 1987; Vol. 119, c. 311.]
I find that difficult to believe. Indeed, I received a copy of a letter from the National Union of Employees after our last debate on this subject, which had been sent to one "J. Moore, MP, Secretary of State". In that letter, dated 16 June, the union made various allegations about the number of ambulances that were single-manned. It said that, on 24 May, there were 39 single-manned ambulances and that the number of ambulances "unmanned or immobilised" was 26. The union sent the evidence to the Minister and asked him to do something about it.

I do not know what has happened since then, but I hope that there has been some change. I have been given to understand that, since about June, there has been a change in the arrangements for overtime and the manning of ambulances. There has been some relief of the conditions and this may be due to what I call "cascade capping" of ambulance stations. If so, that is welcome. It may have had something to do with the questions that I have asked. It may have had something to do with the previous debate. I hope that it was.

It is also true that, since that time, there have been other problems as a result of additional demand. I suggest that additional demand occurs if hospitals are closed, as they often are, and therefore journeys are longer. I have been told that quite a lot of the work of the emergency ambulance service is now to fill in the gaps in the non-emergency service. That work involves the transport of patients from one hospital to another because of the closure of wards, the shortage of nurses and the fact that operations must be done elsewhere or not at all. In other words, there is a cascade effect on the ambulance service as a result of all the problems of which we are aware. There is a knock-on effect, or, more graphically, a knock-back effect.

I am told that, as a result of those problems, there were discussions with the ambulance men about spreading the resources in different ways. There were new ideas about shifts and transferring ambulances from areas that were relatively well off to those that were not. I believe that that meant that resources were spread more thinly. It is no surprise to learn that there have been some industrial problems, and the Minister may refer to them. However, I understand that they have been resolved.

The question of spreading resources brings me directly to the standards that are laid down by the Department of Health and Social Security. I hope that the Minister agrees that those standards are right and that the service and its budget should be built upon them. The basis for those standards is derived from the ORCON standard, and to show how that standard applies to London I wish to quote from the report made to North East Thames regional health authority at its meeting in September 1987 regarding the ambulance service. Paragraph 11 states:
"The Emergency Call standard is that 95 per cent. of calls must be activated within 3 minutes of the receipt of the call"—
that is, activated from the central control.

"For the L.A.S. as a whole the current standard achieved is 91 per cent. and for the North East Division, 93 per cent.
In addition in metropolitan areas it is recommended that for 95 per cent. of emergency calls the scene should be reached within 14 minutes of the receipt of the call. For the North East Division the figure is 17 minutes with 87 per cent. of emergency calls responded to within 14 minutes. In the service as a whole, 89 per cent. of calls are reached within 14 minutes."
Most of those standards, therefore, are not reached. Paragraph 12 states:
"The activation times for emergency calls achieved by the L.A.S. leaves room for improvement and it is expected that when the Central Emergency Control has been updated activation times will be reduced. However, the project is now running two years behind schedule and consideration is being given to bringing some of the new components, such as up-to-date telephones, into the existing Control.
Given traffic congestion in London, which is particularly bad in the North East Division it is unrealistic to expect that 95 per cent. of all emergency calls will be met within a response time of 14 minutes. The L.A.S. Short-Term Programme for the current year proposed a figure of 90 per cent. as a target and this has been accepted by the managing authority. Achievement of this target in the North East Division will be assisted by the review of the A. and E." —
that is, accident and emergency—
"rotas currently being undertaken."
In plain language, that means that, because of traffic congestion in north-east London — and we all understand the problems — instead of upping the equipment and manpower, the service is reducing the standard. As an east London Member, I do not consider that satisfactory. It should be the other way around. I am not saying that every year the standard will be hit: that will not necessarily always happen. However, deliberately to reduce the standard is surely to go about matters in the wrong way, and it is not untypical of what has been happening.

Let me now deal with the problem of equipment. There is dissatisfaction with some of the vehicles, which, I suppose, is to be expected. I understand that Britain does not produce an ambulance chassis: I do not think we ever did. That is a great pity. We might have led the world, and I am sure that design and practice in London could have led Britain—as, I believe, it used to in the days of the London County council, when our great Daimler ambulances were much admired throughout the world. Why can we not bring that back? I am sure that there would be plenty of enthusiasm among staff and experienced officers if it could be done.

The question of control equipment was mentioned in the extract that I have just read. I have also been told that for the sake of economy, less experienced people have been employed in the control room. I can think of nothing that would reduce the morale of ambulance men more than for people to be in control who had not been out on the job.

If I may he a little imprudent, Madam Deputy Speaker, it is rather like someone occupying the Chair in the House without having been a Member of Parliament. I cannot imagine hon. Members agreeing to that for a moment.

Why should ambulance men out on the job speak over the radio to people who have little insight into the job that they have been doing? Surely that is absolutely wrong. I believe that it has happened, but that there may be second thoughts about it; if so, I hope that there will be some very quick thinking.

Let me now refer to the vexed question of defibrillators. I shall not go into alternative descriptions of them, as the Minister is here tonight. However, I understand that they are a life-saving apparatus used in cases of heart failure, and there is a possibility that they can be placed in all emergency ambulances. Indeed, I understand that some ambulances already contain them. I am told that in the East Ham depot, in my borough of Newham, there is one defibrillator; in West Ham there is none. I understand that in some parts of the country most ambulances are fitted with them. What I do know is that ambulance men are encouraged to go round with begging bowls and ask the public, industrial firms and charitable bodies to give money for defibrillators to be fitted in their ambulances. I am told that they cost between £2,000 and £3,000 each. What is that—one-tenth of an ambulance man's pay for a year? I do not know, but it is something of that sort.

I should like to know from the Minister — if not tonight then at a later time—what the national policy is on defibrillators. Can they not be fitted to every ambulance, or need they not be fitted? Are they being over-publicised? Or is it just a gimmick? Do the Government really think it meet and proper for ambulance men to spend their hard-earned spare time going round running raffles and doing all these charitable works which are sometimes advocated by hon. Gentlemen on the Government Benches to get extra equipment for their ambulances? Nothing could be more demeaning, and nothing could demean the Government more if that is their policy. If it is their policy for machines which are unnecessary, it is worse; and worse still if the machines are necessary and are not supplied out of public funds.

The mention of public funds brings me back to the budget. I quote from another reply that the Minister gave me on 10 July 1987:

asked the Secretary of State for Social Services what arrangements he has made with the London ambulance service to provide it with sufficient funds for the year 1987–88 to enable it to respond to the annual pattern of emergency service demands for its services within the established standards of response times.

We have made no arrangements direct with the London ambulance service. The South West Thames regional health authority is responsible for managing and funding the London ambulance service and will no doubt take into account the expected levels of emergency calls and the minimum response times that the Department recommends in setting the budget."—[Official Report, 10 July 1987; Vol. 119, c. 312.]

That is an extraordinary answer because, as the hon. Lady told me in the debate, the South West Thames regional health authority had ceased to precept on the other four regional health authorities for funds.

I quote now from the same North East Thames regional authority's report, paragraph 8:
"With effect from 1987–88 the South West Thames RHA receives a financial allocation for the LAS directly from the DHSS, replacing the former method of proportional allocations from each of the Thames RHAs. The revenue cash limit for 1986–87 was £14·714 million and an overspending of £0·541 million will be a first call on the 1987–88 budget. The LAS is subject to a 0·25 per cent. p.a., budget reduction over the Strategic Plan period."
I read that as meaning that out of the £14·714 million for 1987–88 £541,000 has to be paid back for an overspend in the previous financial year. Of course, it could have been taken account of in the allocation by the Department of Health and Social Security, but it was an allocation by the DHSS which the Minister seemed to dodge in the answer to the question that I have just quoted.

But, in addition, we are told, there is a 0·25 per cent. budget reduction — I believe that it is called the "efficiency factor" or something like that. It is quite obvious, therefore, that the London ambulance service is being funded by a method which is not clear to this House.

As I have suggested—and I do not think that anyone could possibly disagree—the London ambulance service must be demand led. It must keep to the ORCON standards, and be so managed and equipped with vehicles as to enable it to meet that demand. It may be that the demand for emergency services is increasing. It is within the discretion of the doctor to decide what is an emergency. There will be more road accidents, arid difficult cases may have to be transferred. Heaven help us if there is another disaster, but the risk factor must always be taken into account. We must remember that another disaster such as the one at King's Cross may occur, so there must be sufficient ambulances to ensure that, while that disaster is being dealt with properly, other places have sufficient ambulances to cope.

I accept that there must be a balance, but surely when a budget is made it must be based on experience of demand, with the ORCON standards being applied, and it can then be decided how many vehicles and men are necessary. I have no evidence from the debates that we have had — I hope that another debate will not be necessary and that this will be the last—that that is the process that occurs in the DHSS, South-West Thames regional health authority or at ambulance headquarters at Waterloo.

The Minister went to King's Cross and praised the ambulance service and the other services. I hope that she will consider what happens at ambulance headquarters at Waterloo. The office is working under considerable difficulties, because it is trying to eke out the money that is made available and dealing with industrial relations problems that have arisen because the money is not sufficient to do the job. I hope that the hon. Lady will translate her words at King's Cross into action at Waterloo.

5.26 am

The debate is important and timely. It is appropriate that we should be discussing this subject, and I should like to pay tribute to my hon. Friend the Member for Newham, South (Mr. Spearing) for his assiduous work in continually exposing the cuts that have taken place in the London ambulance service over the past few years and for speaking up for the people of London on this matter.

I am sponsored by the National Union of Public Employees, which has a large number of London ambulance service employees in its membership. It is in that regard that I am speaking, but I also represent a constituency in which the level of car ownership is one of the lowest in London. My constituents obviously rely on the ambulance service for dealing with not only emergency but non-emergency cases to a greater extent than areas where there is a high level of car ownership. However, in those areas people are increasingly being forced to use their own transport to get to and from hospital.

A couple of weeks ago the Prime Minister, the Minister and almost every other hon. Member quite properly praised the emergency services — the police, the fire service, the ambulance service and station staff — on their heroic efforts at King's Cross. A circular has just been distributed giving national salary rates for ambulance staff. I shall quote them because it is relevant that people understand the level of pay that ambulance staff receive, commensurate with their responsibilities and duties. A leading ambulance man, as fom 1 April 1987, is on an annual rate of £10,330, which is less than half that of a Member of Parliament. A qualified ambulance man, employed on a range of ambulance duties, receives £4·59 per hour; an ambulance man receives £3·33 per hour and an ambulance cadet receives £1·95 per hour. They are not high rates of pay by any stretch of the imagination yet the responsibilities of the job are awesome.

The King's Cross disaster was horrific by any stretch of the imagination. It was a complicated issue with which to deal because of the fire in the tunnel, the necessity of getting people out of the tunnel, the problems of smoke inhalation, and so on. Thirty people died, a further 20 were seriously injured, and obviously many people suffered from shock and had to be removed to hospital. That disaster caused chaos throughout most of north London and it certainly had a significant effect on the emergency services throughout London.

It is important to understand that, despite the horror and magnitude of the King's Cross disaster, the emergency services just about managed to cope. I dread to think how they would cope with a disaster of the magnitude of a Boeing 747 or equivalent airliner coming down over London. That would mean dealing with at least 500 casualties immediately — one would expect all the passengers to be casualties—and if the plane came down in a densely populated area it would cause serious injury to people in the area.

I hope that the Minister will listen to my point and answer it seriously. If the ambulance service was so totally stretched at King's Cross, how would it cope with an enormous disaster in London? The answer is that it could not. On the night of the King's Cross fire there should have been 85 ambulances available to go to the scene. Only 40 were able, because there was shortage of vehicles, drivers and the controllers to get them there. The consequence was that in other parts of London there were long response times for ambulances to go to emergencies such as heart attacks and so on when people need to be rushed to hospital.

On 26 November, the night on which we were discussing the problems of funding in the NHS, which was only a week after the disaster, there was such a shortage of controllers at the London ambulance headquarters in Waterloo road that the north-west and north-east sectors of London had to be linked to deal with control work that night. That obviously meant a less efficient service by any stretch of the imagination.

There was a threatened emergency at Heathrow airport on 24 November. I understand that only one LAS ambulance was able to go immediately to the airport to deal with that potential disaster. Fortunately, there was no disaster, but there was a shortage of ambulances to go to Heathrow on that occasion. The hospital alongside Heathrow airport, the Central Middlesex hospital, has a casualty unit so under-staffed that it has been on absolute emergency only for the past 18 months. I raise these matters because it is not good enough that London's emergency services should operate on the knife edge of survival at present. The London ambulance service is an example of that.

In days gone by the London ambulance service was a local authority responsibility, in common with other parts of the country. It was run efficiently by the Greater London council for several years. Staffing levels were higher, the availability of vehicles was higher and the ability to deal with London's health problems was certainly better than it is now. It was then taken away from the GLC and, as we know, the GLC was abolished in an act of vindictiveness unparalled in modern politics.

London Health Emergency, which is a health watchdog body that has done excellent work, produced "Ambulance Alert" in 1986. That showed the growing crisis facing the London ambulance service. The report was made available to the DHSS, and I should be interested to hear the Minister's response. The report showed that at that time the LAS achieved the standard required — that 50 per cent. of emergency calls should be responded to within seven minutes — only 25 per cent. of the time. That meant that in relation to total emergency demand of 469,000 calls, 117,000, were not reached within the appropriate time. If one assumes — it is a reasonable assumption — that 1 per cent. of the calls are critical, that means that 1,173 people in London were put at serious risk due to the inability of the service to meet demands at that time. Those figures are for the final quarter of 1985, and the picture has got considerably worse since then. I stress the fact that the figures refer to 1985 because that is the time covered by the report.

In June 1985, the four trade unions that represent the London ambulance service — the National Union of Public Employees, the Confederation of Health Service Employees, the General, Municipal, Boilermakers and Allied Trades Union and the Transport and General Workers Union — carried out a monitoring exercise of the emergency service in relation to the ORCON standards. They concluded that only 45 per cent. of 999 calls met the standards, that 50 per cent. were delayed by up to three minutes and that 5 per cent. were delayed by six minutes or more. "Ambulance Alert" says:
"As the Strategic Plan 1984 concedes, only one survey of the non-emergency service had been done over the last 12 months. Indeed the Strategic Plan makes it clear that the standards are now generally disregarded. In referring to standards, it says: 'There is little doubt however that compared to the target standards established in the ORCON Report of 1974, the poor performances identified in former years still prevail in many areas'."
It is important for the House to understand that people who work in the ambulance service have an esprit de corps. They are determined that their service will be run efficiently. They regard themselves as being in the front line and take a pride in the service that they provide. It is difficult for them to be proud, however, when they see nothing but cuts all around them and difficulty in meeting the response times that they want to achieve because of restrictions. Their suggestions are advanced in a spirit of wanting an efficient service.

London has special problems. It has a fluctuating population, as most tourists to Britain visit London. It also has enormous traffic congestion problems which seriously affect the ambulance service. The average speed of an ambulance in the morning peak period has fallen during the past 15 years from 13·9 mph to 12·6 mph in inner London. That is a 9·3 per cent. reduction. The average speed in the evening peak period has fallen from 13·7 mph to 12·2 mph—an 11 per cent. decrease.

The recent accident near Blackfriars bridge caused chaos which took five hours to clear, and a burst water main at Swiss Cottage created problems which took four hours to clear. Those examples demonstrate that the service always operates on a knife edge. I hope that the Minister realises that the service needs more ambulances and funding to cope with those problems.

The closure of hospitals and the trend to centralise services in one district general hospital create longer journey times for ambulances. My borough lost the casualty unit at the Liverpool road hospital some years ago. More recently, it lost the Royal Northern hospital, so we have only one casualty unit at the Whittington hospital. Casualty units in Haringey were closed and transferred to the North Middlesex hospital. The same has happened in Hackney.

I hope that the Minister will make a considered and reasoned response to the London Health Emergency report. She ought to realise that the shortage of staff in the ambulance service means that non-emergency patients are often kept waiting unacceptably long. Indeed, in some cases, even emergencies are kept waiting. That demoralises staff, which leads to absenteeism and pressure on crews. There has been a serious increase in the number of assaults on staff by those to whom they go. The number of days lost due to sickness has risen from 3,864 in August 1983 to 4,406 in August 1985 — a 14 per cent. increase. In August 1983 there were 124 assaults on staff; and in an equivalent period in 1984 there were 120 assaults, 96 on men and 24 on women. Those are serious matters and I trust that the Minister will look seriously at those problems experienced by the ambulance service.

In the provision of emergency services the ambulance service must be demand-led, but in the non-emergency services cuts of misery are being made. The ambulance service is continually reduced, hospital appointments are missed because an ambulance is not available, and there is the increasing pressure of privatisation which leads to greater inefficiency in hospitals. A patient fails to come in because an ambulance is not available and the time of the consultants, nurses and the hospital is wasted. That is an inefficient way in which to run the Health Service.

It is also inefficient for ambulances to make long journeys when taking people to hospital. It is also unfair on the patients concerned. An elderly lady in my constituency told me that it took two and a half hours to get to hospital in an ambulance. She did a tour of half of north London, something that she could have done without on a winter's morning. It would have been better for her and for the hospital if she had gone there directly.

When this report was produced, several conclusions were reached, and I want to highlight two of them. First, incredible secrecy surrounds the London ambulance service and the regional health authority. In the days of the GLC it was easy to get information on the number of controllers, vehicles, and so on, available at any one time, but that is now difficult to obtain and it should be freely available to the public. [Interruption.] I do not know what is exciting the Minister, but no doubt she will contain her excitement until I have finished. The cut in resources and the rise in demand call for greater public expenditure on the ambulance service. That has not happened. Indeed, the reverse is the case.

The Government's policies towards community care, which are controversial, to put it mildly—many of us see those policies as a hidden cost-cutting exercise rather than an improvement in the quality of care— can also mean greater demand on the ambulance service which has not been sufficiently funded to meet such demand.

In a statement in late 1986, about a year ago, it was clear that non-emergency patient journeys — those carried by London ambulance service personnel—had fallen from 39,560 a week in 1984 to 27,507 in 1986. The biggest weekly reduction was in the number of walking patients was a fall of 44 per cent. Unfortunately, the term walking should be in inverted commas. The people to whom that phrase refers are often elderly or disabled, but, because they are so categorised, people assume that they can walk to hospital. I have met some of those patients struggling along the Holloway road trying to get to the Whittington hospital because there is no ambulance to pick them up. It is an insult to call such people walking patients. They clearly deserve and need help and sympathy, but they are getting the very opposite.

There are ominous trends towards privatisation in the ambulance service. When the Minister replies, I should be grateful if she would tell us her Department's policy on that. We know that, for example, the Hampshire ambulance service tried a privatisation scheme with contracts with various taxi firms in that area. It tried to take the work away from the qualified ambulance personnel and pass it over to non-qualified people running minicab services and the like. I have a horror of that process.

Instead of qualified ambulance personnel being available to deal with non-emergency cases, increasingly the trend is either the use of a minicab service or of volunteer drivers. Indeed, before my father died he was ferried to the hospital for physiotherapy by a volunteer car driver. He was a very nice man, but he was a volunteer car driver who was trying to do his best and thought that he was helping out. There was nothing wrong with that man except that he was totally untrained for the work and did not have any qualifications for it. Therefore, when somebody such as my father, who was suffering from cancer and could not walk properly, fell over, that man did not know what to do. He had to call on neighbours or passers-by to help him. It is true that on that occasion I was able to get to the scene quickly and assist, but on other occasions there might not be anybody who could get to the scene.

It does not do much for the confidence of relatives—or, indeed the patient—to know that the person who is driving the car is not prepared or qualified to deal with emergencies. It is not good enough to expect volunteers, minicab drivers or anybody else — whatever their motives—to be able to cope with such problems, but that is exactly what is happening in the ambulance service at present.

I turn now to the question of staffing numbers in the ambulance service itself. In May 1985, there were 2,099 whole-time equivalent employees in the London ambulance service, of whom 60 were qualified leading ambulance men. In May 1987, the figure for whole-time equivalents had grown to 2,227·5 except that only 57 were qualified leading ambulance men. In other words, there were three fewer. The number of grade 4 qualified ambulance persons had also reduced from 1,560 to 1,509. Part-time ambulance persons, who had by then been introduced, had increased to 97·5 whole-time equivalents but, in terms of actual staff in post, had increased to 195. The trend appears to be to reduce the number of leading and qualified ambulance staff and to increase the number of part-time staff, with the unfortunate consequences of that. As a result, there has been a fall in the number of leading qualified ambulance staff.

Patient journeys undertaken by the London ambulance service have changed a great deal between 1985 and 1986. I accept that that is only a short period, but if the trend is extrapolated forwards—or even taken backwards—one can see that the figures that I am quoting show a trend and it is, therefore, perfectly valid to quote a year-on-year figure for this.

In 1985, of total patient journeys in thousands, there were 2,680·7 of which 90·6 per cent. were directly provided by the London ambulance service; 4·1 per cent. by agency services; 4·5 per cent. by hospital cars; 0·6 per cent. by other means and 0·1 per cent. by rail and air. In 1986, the number of directly provided journeys had decreased from 2,429·3 to 1,988·2, which is a drop to 85·2 per cent.; agency services had increased to 5·2 per cent., hospital cars to 7·7 per cent. and others to 1·8 per cent. In other words, the trend was a reduction in the number of journeys undertaken by the ambulance service itself and an increase in the number of journeys undertaken by hospital cars and other kinds of service. Therefore, the number of directly provided patient journeys fell in both absolute and proportionate terms while the number of journeys made in hospital cars increased, again in both absolute and proportionate terms.

A year ago, in December 1986, I asked a whole series of questions of the Minister's predecessors about these matters. The answers showed that emergency patient journeys in the London ambulance service had increased from 333,000 in 1979 to 476,000 in 1985. The number of non-emergency patient journeys totalled 1,680 in 1979. They increased to 2,302—a high point —in 1983, and went down to 2,205 in 1985. I suspect that the trend is continuing in that direction.

I then asked the Minister some questions on training. We are well aware and understand what training is given to qualified leading ambulance men, but there appears to be a trend, which is confirmed by the figures, of increasing the proportion of unqualified staff at the expense of qualified staff, and of the use of hospital car services increasing that number by an enormous amount, which suggests that they will be made by unqualified people. Indeed, on 16 December 1986, I asked the Secretary of State for Social Services
"how much money has been paid to hospital car drivers in each of the London Ambulance Service areas for each year since 1983." —[Official Report, 16 December 1986; Vol. 107, c. 468.]
We find that in 1984 the figure for north-west London was £75,829. By 1986–87—the current year—it had gone up to £120,000. In north-east London, it was £76,000 in 1984–85, and up to £155,000 in 1986–87. In south-west London it was £97,000 in 1984–85, and up to £158,000 in 1986–87. In south-east London, it was £100,000 in 1984–85, and up to £171,000 in 1986–87. The total figure for 1986–87 was £604,180 paid to the hospital car service, at the expense, I contend, of the ambulance service. These are serious matters. It is not good enough to allow such a trend to continue, with the damage that it is doing to the quality of service in London as a whole.

It is also interesting that, on 12 November this year, a circular was sent out from the DHSS about EC drivers' hours regulations. It states:
"The Department of Transport in consultation with the DHSS has been considering the application of the revised Drivers' hours regulations to the Ambulance Service. In the opinion of the DOT the regulations apply".
It then gives the circumstances in which the regulations apply, and goes on to state:
"Emergency ambulances are exempt from the EC Drivers' Hours and Tachograph rules. They are only subject to domestic regulations.
The limits on rest time, breaks, maximum duty without a break and daily 'spread over' have been abolished for domestic driving. The daily driving limit of 10 hours and the daily duty limit of 11 hours are retained."
I quote that circular because it is not satisfactory that the restriction on hours that applies to other drivers should be lifted in the case of ambulance staff. It seems to be a trend of putting unacceptable pressure on ambulance staff to work unacceptably long hours. That is obviously detrimental to them and to the service as a whole.

Those who work in the London ambulance service are people of enormous dedication and skill. They do not like the staff cuts. They do not like their inability to meet the ORCON response times. They do not like the shortage of controllers. Enormous pressure is put controllers at the London ambulance service headquarters. The psychological pressure of not being able to cope in an emergency is quite appalling. It is a day in, day out grinding fear. Air traffic controllers, fire controllers and so on in London are put under the same enormous pressure. It is not acceptable, sane or sensible for the capital city of this country to have its emergency services working on a knife edge of survival, day in, day out. The ambulance service needs to be looked at. I hope that the Minister will be able to give some hope to the people in the ambulance service who want to see the service restored to its former level of glory and efficiency, rather than see people forced to use mini cabs, private cars, volunteer drivers and so on, and the unsatisfactory nature of that service.

Many people in London have enormous regard and respect for the ambulance service and the work that it does. That is right and proper. But they also feel that while they are waiting around for hours and hours for ambulances to arrive in non-emergency matters, or, in some cases, having to wait an unacceptably long time for an emergency ambulance to arrive, their confidence in the service is diminished. We in London are getting a second-rate emergency service that is increasingly relying on volunteers.

When the ambulance service in London is cut back, as it has been cut back, the poorest people suffer. Those people who have access to a car or can afford a car or minicab can get to the hospital for a casualty admission, which may not be an emergency, but poor people have to wait and wait, and that is the worry.

I hope that when the Minister replies, she will tell us that the continual curtailment of expenditure by the London ambulance service and this process of diminishing service and expenditure will come to an end. I hope, too, that she will recognise the value of the ambulance service and increase expenditure on it accordingly.

5.55 am

The Parliamentary Under-Secretary of State for Health and Social Security
(Mrs. Edwina Currie)

I congratulate the hon. Member for Newham, South (Mr. Spearing) on winning a place in the ballot and on raising yet again the question of the London ambulance service. I have taken note of the concerns that he has expressed and I hope that I shall deal with them as I make my speech.

Order. Does the hon. Lady seek the permission of the House to speak a second time? I believe that she has already spoken.

I apologise, Madam Deputy Speaker. If I may speak, with the leave of the House.

I will go away!

I have noted the points raised by the hon. Member for Islington, North (Mr. Corbyn), and I share his concern about violence against staff. He will know of the efforts made during the past year by a committee in the other place. Considerable effort is being made to assist and advise staff, and to ensure they are not put at risk. Unfortunately, for ambulance men, I am afraid there will be occasions when that is almost unavoidable, but we will do whatever we can to minimise that risk.

I welcome the fact that studies are continuing on this matter. Will the hon. Lady give us an idea of when this committee will report and make its recommendations?

It has, as I recall, already produced some guidelines on social services, which was the original reason for the committee being set up. I shall write to the hon. Gentleman.

The hon. Gentleman went on to complain about how difficult it was to get information and how much easier it was when the GLC ran the ambulance service. He then produced strings of information, much of which I had provided through parliamentary questions and the various debates initiated by the hon. Member for Newham, South. I am very glad that the hon. Member for Islington, North has noticed the amount of information. In 1986, when all this business was going on, he spent a lot of time away from London, in El Salvador, Florence, Cuba and Nicaragua. He also went to Pisa and Copenhagen, he was at the Fenestras conference in El Salvador, and he visited India and Bangladesh. At least this time he is talking about his own constituents. That is where he was in 1986, according to what he has declared in the Register of Members Interests. I am not surprised that he missed some of the information that the hon. Member for Newham, South and I were sharing.

I hope the Minister will accept that she is making a very cheap point. If she knows London and knows of the activities of my hon. Friend the Member for Islington, North (Mr. Corbyn) in London, or if she ever listens to London radio or reads a London newspaper, she will know that my hon. Friend is extremely active in his constituents' interests. She does not have to think that he is like some Conservative Back Benchers who cannot walk and chew gum at the same time. My hon. Friend manages to be a good internationalist and an especially assiduous local Member of Parliament at the same time.

I am sure that the hon. Member for Islington, North is very grateful for that little reference, and I am sure also that his constituents have heard it.

Let me put in context one or two statistics which I think the hon. Gentleman probably missed. The London ambulance service runs to 1,000 vehicles. I said that in a reply to one of his hon. Friends earlier this year, and the reply is in Hansard. The service answers emergencies at the rate of 1,300 every day of the year. The average ambulance journey in London costs £18. We have no end of statistics. I am more than happy to go on providing hon. Gentlemen with all the statistics they want; what they do with them is another matter. I hope at least that they understand them. I suspect from what they have been saying tonight that they do not entirely understand them.

It is appropriate for me to say something at the outset about the ambulance service and the work that its staff do. The service has been the subject of much scrutiny and change recently, partly as a result of the Rayner scrutiny of the non-emergency services, and partly as a result of the new pay structures that were introduced last year. Both had far reaching consequences for the service.

Without the intrusion of any partisan element, want to pay tribute to the ambulance men and women who provide us with an excellent service and carry out demanding jobs. The most recent examples of that were during the storm on 16 October and, as hon. Members have mentioned, during the fire at King's Cross station. One of the reasons why I went immediately to the scene of the fire was that I am responsible for aspects of disaster planning. I am completely satisfied that the ambulance service, and all the services involved, coped brilliantly with what was a terrible tragedy. I am sure that one of the reasons why there were fewer ambulances than Opposition Members have claimed were needed was that, sadly, there were comparatively few live casualties. I was reliably informed by everyone I met that the ambulance service coped and that, people were satisfied.

I, too, pay tribute to the ambulance staff, who coped magnificently that night. However, has the Minister studied the effect on other parts of London of the movement of ambulances towards the King's Cross fire and the response times achieved in other parts of London for individual emergencies that night?

It is all a matter of judgment, particularly for the staff in charge, of what is the major priority on any occasion. If there is a major disaster, we expect services elsewhere to be affected. I had some difficulty in getting to the House on the night in question because of the amount of emergency traffic in the neighbourhood. The service responded brilliantly that night, and I have no doubt that it not only saved lives but relieved a great deal of the worry and pain of those who were not badly injured, but needed assistance.

The ambulance service is often the public's first contact with the Health Service, which gives it a special responsibility. Like many other aspects of the Health Service, some of which we rehearsed earlier, it tends to be taken for granted until it is needed. Like many other free services, it is occasionally abused by thoughtless people. I am sure that Opposition Members would not deny that. It happens, and it has happened. The people with whom we are dealing are not perfect.

About 20 million journeys are undertaken each year by the ambulance service in England. In 1985–86 the London ambulance service carried ·5 million 999 patients, which is an astonishing figure.

In March last year the new salary structure for ambulance men came into effect and radically changed the pay arrangements for ambulance personnel. It provided an opportunity for all ambulance services to rid themselves of what were readily admitted to be inefficient working practices, most of which, sad to tell, Opposition Members seemed to support. It was intended that the changes should lead to an ambulance service that was more sensitively geared to patients needs, in terms of staff deployment, rather than to custom and practice.

Concurrently with the introduction of this new structure, the London ambulance service took steps to improve the front line—the emergency service. It had little choice but to make improvements to the part of the service that was involved in many cases with the life or death of a patient. In doing so, staff resources had to be transferred from the non-emergency service to front-line work. That left the London ambulance service short of non-emergency staff — or shorter than it would have wished — and it introduced urgent measures to try to curtail demand on the non-emergency work so that it could continue to provide for the patients who most needed its services.

The South West Thames regional health authority, which manages the London ambulance service on behalf of the four Thames regions, took immediate and successful steps to increase recruitment to the non-emergency service to make up for the shortfall. I have answered questions raised by the hon. Member for Newham, South and by other hon. Members who have requested details of progress with recruitment during the past year and a half. The hon. Member for Islington, North accurately quoted the figures. I am more than happy to repeat them.

The number of leading ambulance men in May 1985 was 60. By May 1987 that figure was 57. That represents whole-time equivalents. The number of grade 4 ambulance persons was 1,560 in May 1985, and by May 1987 it was 1,509. The numbers of grades 1, 2 and 3 ambulance persons were respectively 53, 237, and 189 in May 1985, making a total of 479. That had risen to 564 by May 1987, and the number of part-time ambulance people was nil in May 1985. It was 97·5 whole-time equivalents in May 1987, which is 195 staff. That is how we run a better service on a tighter budget. We have slightly fewer chiefs and rather more Indians. It is also worth putting on record that the ambulance service accepted a 5 per cent. pay rise on 27 November.

Part-time employees were introduced into the London ambulance service only 18 months ago to try to make the work force as flexible as possible in order to cover the different and increasing demands that Opposition Members have described. In addition to the nearly 200 people now employed on a part-time basis, there has been a significant increase in the number of full-time ambulance staff. Almost every month in 1986 about 30 people were going through training in the ambulance service in London and with low resignation rates we are now seeing the benefit of this sustained recruitment campaign. The first crew on duty at King's Cross had only recently finished training and was new to the service.

The total numbers of staff now employed is higher than it was two years ago before the upheavals of reorganisation began. Nobody can complain that the staffing of the London ambulance service has not responded dramatically to the early criticisms. There are now about 2,325 people employed by the service, compared with 2,099 two and a half years ago.

I shall now deal with the reduction in the number of non-emergency patient journeys. I can confirm that there has been a reduction in the number of journeys undertaken. As I have done before, I should like to make some comments about the reason for that reduction. First, as I have already said, the London ambulance service was short of staff at the beginning of the year starting on 1 March 1986, about 18 months ago, because of the move of some non-emergency staff to front-line work. Inevitably, that resulted in a reduction in the number of journeys that it was able to undertake. Secondly, for many years there has been much concern about the use of ambulances for patients who have no medical need for them. The hon. Member for Islington, North may well have a view about the medical need of patients, but the only person who can decide is a doctor. Neither the hon. Gentleman nor I can decide.

Particularly since the Rayner scrutiny report in 1984 on non-emergency ambulance services, health authorities have been encouraged to identify and eliminate potential abuses of ambulance transport. Ambulance transport is provided for patients using the Health Service who, in the opinion of the clinician in charge of their case, are unable to travel by any other means. The advice to health authorities is clear and is in circular HC(78)45, paragraph 2, which I think was issued by the last Labour Government. That advice also makes provision for ambulance transport in some cases where patients do not have access to private transport and public transport is not available. This criterion is unlikely to be applicable within the London ambulance service area, although it may well apply in my constituency in Derbyshire.

Some out-patients who formerly enjoyed transport by ambulance were not strictly eligible for other reasons, either because they were able to travel by other means or because they were being transported to locations outside the National Health Service, such as, to social services day departments or day centres. The NHS does not carry the responsibility for transporting passengers who are not patients. Doctors are asked to take care in authorising ambulance transport and to ensure that they consider the medical need criterion, especially for patients who undertake a course of treatment involving a number of routine attendances at out-patient departments. At first, ambulance transport is appropriate and reasonable for such attendances, but, with progress in the patient's condition, that becomes unnecessary. That means refusing people a service that they had before and, naturally, they may feel aggrieved. However, it is right to refuse that service.

The Minister has not reconciled her answer with her letter to me about abuse. There may have been marginal problems, such as the ones with the social services, which could have been ironed out, but a massive cut of 40 per cent. surely needs more explanation than the rather administrative jargon that the Minister is pumping out.

I am doing my best to answer the hon. Gentleman, but as I told him at Question Time recently when he raised this matter, he never likes my answers, and I suspect that he never will—

— but I shall go on giving them in the way that I wish and in the way that I think is right. So long as I stand at this Dispatch Box I shall give the answers, and he will no doubt go on disagreeing with them.

There have been calls for the criteria for ambulance transport to be extended to include social and economic grounds, for example in a report published last year by Age Concern. I have every sympathy with pressure groups which we fund, which fight hard for the interests of their clients, but the NHS resources must be used efficiently and for health purposes and health care and not for other purposes. The ambulance service must be included in this. It is not a taxi service. Nor is it a bus service provided free of charge. It is a highly specialised service with skilled personnel. To use it as a free bus is the equivalent of using an operating theatre for a tea party.

Will the Minister comment on what the Medway health authority thought was the economical use of the ambulance service? I cite the case of Hayley Girt. The ambulance was called at Sheppey hospital at 1.1 pm. Hayley Girt had been bitten by a dog and needed stitches and had to be transferred to East Grinstead. Because of the excessively economical use of the ambulance it went to various parts of the area to pick up people, and Hayley did not arrive at East Grinstead and begin to have stitches in her face until 4 pm. Would the hon. Lady regard as economical use of a non-emergency ambulance a child having to wait three hours to have stitches in her face, having had to go all over the country before getting the treatment that she needed?

When she sends it to me, I will respond with pleasure. With the scale of activity of the London ambulance service, it would be absolutely amazing if there were not occasional problems. It would be nice—and the ambulance staff would welcome it — if Labour Members, including the hon. Lady, praised the service sometimes for the exceptionally high standards that it achieves most of the time.

There are provisions for patients who do not qualify for ambulance transport to have their travel expenses to hospital paid under the hospital fares scheme. Help with the cost of travelling to and from hospital for treatment is given automatically to people in families whose heads are receiving regular weekly payments of supplementary benefit or family income supplement. I suspect that that is not nearly widely enough known or widely enough claimed. In addition, help is provided for people in families whose income after payment of the travelling expenses in question would be barely sufficient to cover their requirements, assessed broadly by supplementary benefit standards. This assessment takes account of the expenditure incurred in attending hospital, and expensive journeys—again, such as those my constituents have to make — could bring patients on a modest or average income within the scope of the scheme.

These arrangements may not cover all cases of difficulty, but they help to remove some of the apparent anomalies to which attention has been drawn tonight. The intention is that help should be given to those most in need. Any extension of the present scheme could have considerable financial implications and we must be aware that that would inevitably divert money from direct patient care.

Will the Minister accept that it is not well known in some circles that such payments are available? In any event they have to be claimed in arrears and are often difficult to claim because of staffing cuts in the section of the DHSS that deals with social security benefits. I have often come across cases of people who have been unable to get to hospital with that kind of assistance because they simply could not claim the money to get there.

I can equally well think of a number of cases, particularly of constituents of mine who have had to travel to London for specialist treatment, who have found it tolerably easy to claim and who have become aware of how to do so through my advice and assistance. It is available and it is part of our job to see that people are made aware of it.

I see what the hon. Gentleman means. I remind him that my majority went up at the last election.

The Rayner scrutiny, to which reference has been made, on non-emergency ambulance services, which we published in March 1984, indicated some inefficiencies, and particularly the lack of any link between controlling the demand for transport and its cost. The scrutiny proposed no change in the basic criteria for ordering ambulance transport, and that remains the position. The responsibility lies with the clinician in charge of each case to request transport for those patients who need it. The ambulance service must then provide the most appropriate form of transport.

It has always been open to ambulance services to use taxis, hire cars or private contractors where it is cost effective to do so and where it is in the patient's interest. That did not just start in 1984. The scrutiny report underlined that and reminded us of it. It encouraged a more flexible approach to solving transport problems. That means that health authorities are indeed considering the benefits of using private sector vehicles and the voluntary sector where that would best serve patients' interests. Although that trend is increasing, as the hon. Member for Islington, North rightly said, it is not new arid has always been an option that has been used by health authorities around the country.

Private contract or volunteer car driver arrangements can be better for patients in rural areas, and when used appropriately can reduce Health Service costs. I honestly cannot see what is wrong with that. I know that the hon. Member for Islington, North used the word "horror". His approach to this matter is quite ludicrous, and I suspect that the reason he does not like it is that it is a privatised service and therefore not accessible to his comrades in the National Union of Public Employees.

If I may say so, that is an extremely unfair way of dealing with a very serious concern. Many people are worried that well-meaning, but totally unqualified and inexperienced people are taking patients around and that they are unable to cope with an emergency, which might occur while the patients are in the car. It is not the sane, sensible or safe way to take hospital patients around. It is a cut, because it is the ambulance service, not various oddbod volunteers, that should take those people around.

I merely point out that in the west country, where there is a proposal to remove the service, people are up in arms about it. They have no worries about whether the driver can respond in an emergency.

No, I do not have much time and I listened to the hon. Lady for 27 minutes in the previous debate and I have not finished what I want to say.

Quite right.

The hon. Member for Islington, North also raised the question of the GLC. I know that Opposition Members would love to see the return of a body like the GLC. Heaven help us. I cannot imagine anything worse. The GLC is dead. Like Mr. Cleese's parrot, it is an ex-GLC. It no longer exists.

At the moment the London ambulance service is managed by the South West Thames regional health authority on behalf of all the Thames regions within the Greater London area. The area is very extensive, the service is the largest in the world, and the health services are concentrated more there than in any other part of the country. Under the management of South West Thames, the London ambulance service has a headquarters and a number of districts from which the day-to-day operation of the service is organised.

With such extensive cross-boundary flows of patients, several of which have been accurately described tonight, between the various district health authorities I cannot see how the present organisation can be further streamlined. Given the hassle which the whole system has undergone in the past year or so, it would prefer a period of quiescence to ensure that the service can be delivered.

I am given to understand, and I believe, that the London ambulance service is now meeting all the demands for non-emergency ambulances that are legitimately being made upon it. There have been steady improvements in the level of service since the hon. Member for Newham, South rightly began to raise the issue. The management of the London ambulance service is not yet satisfied that a compeletely satisfactory quality of service is being provided everywhere. We are always concerned if patients are experiencing delays in reaching appointments or have to wait before being returned home. The problem varies in size from division to division in London. I understand that the north-east division, which covers the constituency of Newham, South, is receiving a very good service.

Steps are now being taken to improve the quality of service everywhere by continuing to recruit part-time staff who will start work at 8 am to ensure that patients are delivered in time for their hospital appointments, and work late into the evening so that patients can be certain of being returned home. Part-timers are being used to provide much greater flexibility in the use of manpower.

The hon. Gentleman mentioned ORCON. I am afraid that he will get the same answer as he has had before—that his constituents get an average 10-minute service. The responses are better this year than they were last year, and we hope to see further improvement. My constituents have to wait much longer for their service and travel much further than anybody in London.

Where the London ambulance service knows that delays are occurring, it is discussing means of overcoming those problems with the hospitals concerned. Extension of the use of the hospital car service is one way in which this is being done. Another is an experiment at the Charing Cross hospital, where a taxi has been provided to act as a sweeper to take four or five patients home if an ambulance would not be available immediately to transport them. I take the point that their journey may be slightly delayed, but they may prefer to be in the taxi and on their way home to having to wait for an ambulance which may have been diverted to deal with an emergency.

The London ambulance service is the biggest in the world. Each of the four divisions that make it up is bigger than most ambulance services in the country, even those covering other metropolitan areas. It is a huge management task, and I have no doubt that if one hunted long enough and ferreted around one could provide problems and difficulties in individual cases.

I am sure they do, but with 5 million emergency 999 patients and 21 million non-emergency journeys per year I am not in the least surprised that some are not satisfactory.

The LAS is taking some measures to improve quality and cut down the inconvenience caused by late arrivals and waiting times. When Opposition Members have genuine specific complaints they wish to raise, I should be more than happy to have them investigated. The hon. Member for Newham, South knows that we investigate all complaints, although it is disappointing that when we investigated some points raised by the hon. Member for Peckham (Ms. Harman) in August of this year we found that they were two years old and had long been investigated and dealt with.

The hon. Gentleman raised a point about defibrillators. I had the privilege of watching the London ambulance service staff being trained to use them. They are used to treat patients whose heart may have stopped. My only criticism of the London ambulance service is that when we were standing around discussing health care afterwards, it turned out that every ambulance man who was being trained to look after heart patients was a smoker, and so was quite likely to need the services of his colleagues if he carried on smoking and suffered heart disease.

I am grateful to the hon. Gentleman.

The high-profile ambulance service is always the object of complaint, rather than the praise that it rightly deserves. The service depends so much on the men and women who staff the ambulances, and I am glad to take the opportunity to recognise the outstanding contribution that they make to the provision of health services.

Does the hon. Lady realise that the complaints have been, not against the ambulance service and the dedicated personnel, but against the Government who do not give the ambulance services enough resources? Will she now say why she disagrees, if she does, with the formula that I suggested at the end of my speech, that the service must be demand-led, be based on the orcon standards, that there must be an arithmetical calculation of what is required, and the Government must provide the money, vehicles and equipment to meet those standards?

I would have thought that providing more staff and a pay rise was a fair start in that general direction. I note the point that the hon. Gentleman has made, and he has had his reply to it on many occasions. I have nothing to add tonight.