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Ambulance Coverage (Forest of Dean)

Volume 458: debated on Wednesday 28 March 2007

Motion made, and Question proposed, That this House do now adjourn.—[Huw Irranca-Davies.]

The Minister of State, Department of Health, the hon. Member for Don Valley (Caroline Flint), will probably be feeling a sense of déjà vu because it was almost a year ago that I called an Adjournment debate in the House on the same subject, and the hon. Lady was answering on behalf of the Government, as she will this evening. My reason for holding the debate last year was to raise local concerns about the performance of the local ambulance service, the then Gloucestershire ambulance trust, which has since merged to become part of the Great Western Ambulance Service NHS Trust.

Last year’s debate followed a specific set of local incidents that highlighted the lack of ambulance cover in the Forest of Dean, which was of great concern to my constituents. We focused in particular on the trust’s use of a matrix system to allocate resources, the result of which was to take ambulances out of the Forest of Dean and other rural parts of the county and to focus on the urban centres of Gloucester and Cheltenham.

Since then, one of my towns, Cinderford, has been given a higher priority in the matrix, which is a positive feature. Unfortunately, however, that has not improved ambulance response times in my constituency. In last year’s debate, I expressed my concern about the impact of the merger on the services that would be delivered in rural areas, and the Minister said that the merger was occurring

“against a background of weak performance in relation to response targets from all three trusts.”

Most importantly, she went on to say:

“We are confident that, while recognising the local issues, larger trusts will deliver a better, more responsive, more efficient service, which people have a right to expect.”—[Official Report, Westminster Hall, 7 February 2006; Vol. 442, c. 229-32WH.]

Unfortunately, the position has got worse since then. In my constituency at that time, about 48 per cent. of category A responses—that is, calls dealing with life-threatening cases—hit the Government’s eight-minute target. A few months later, at the time of the merger, that figure had gone up to 53 per cent. That was still pretty appalling, but at least it was better. Since the merger, the performance has worsened, and the figure is now only 45 per cent., which is unacceptable. When we compare the performance in my constituency with that of Gloucester and Cheltenham, we find that 85 per cent. of the responses in Gloucester and 82 per cent. of those in Cheltenham are within the target eight minutes. That disparity is unacceptable. My constituents pay their taxes just as those in the urban areas of the county do, and they deserve excellent services.

The concerns that I raised last year have turned out to be closer to reality than the assurances that I received from the Minister. My reason for raising the issue again, a year later, is to keep up the pressure on the Government and on the new ambulance trust to provide better services for my constituents. The Minister will be aware that I raised the matter at Prime Minister’s Questions on 21 March. In response, the Prime Minister said:

“In fairness to the ambulance and paramedic services in the hon. Gentleman’s constituency, I think that he will find that they will tell him that they have improved considerably over the past few years. Massive investment is going into our ambulance services and paramedics, although of course we always have to improve on it.”—[Official Report, 21 March 2007; Vol. 458, c. 810.]

Unfortunately, performance is not improving, and I have written to the Prime Minister to point out that fact. I suggested that he might like to use the opportunity presented by this debate to set the parliamentary record straight, and the Minister now has the opportunity to do that. The Prime Minister’s answer did not accurately characterise the situation. I am sure that that was inadvertent and due to the briefing that he had received, but it clearly did not accord with what the ambulance trust has said.

To be fair, the ambulance trust is grappling with one of the issues that the Minister and I discussed in our debate last year, namely, the growth in the emergency call volume, which is rising by about 10 per cent. a year, and in the Great Western Ambulance Service NHS Trust by about 13 per cent. I am not clear—and, to be fair, I do not think that that trust is either—about exactly what is driving those increases. It cannot be the case that we are suddenly experiencing many more emergencies. Indeed, I have received anecdotal reports from the paramedics that my constituents in the Forest of Dean are quite reluctant to call 999. On the whole, when they do so they have a serious problem. They do not tend to call an ambulance at the drop of a hat or in inappropriate circumstances. The evidence that I have seen suggests that that happens less in my constituency than in the urban areas. I would like the Minister to tell the House why the Government think that the call volume is rising. If it carries on rising at 10 per cent. a year without any increase in resources, it will be difficult for the ambulance service to cope.

Anecdotally, paramedics have suggested to me that the change in out-of-hours services—whether real or perceived by constituents—has led to an increase, particularly at night, in parents with sick children and people looking after elderly relatives in distress calling an ambulance because of the lack of a speedy alternative response. I would be interested to know whether the Government think that that analysis is accurate, and what they propose to do nationally to address the growing call volume.

Because of the difficult geography of Gloucestershire, with the River Severn running through the middle of it, the interaction between the Great Western Ambulance Service NHS Trust and those operating in Wales is also an issue. In my constituency, Sedbury, which is the other side of the River Wye from Chepstow, is quite a long way from where the ambulances are based, and also has a significant number of emergency call targets missed. The area is difficult to cover from the rest of Gloucestershire, and I would be interested to know the extent to which liaison between the Welsh Ambulance Services NHS Trust and the Great Western Ambulance Service NHS Trust is possible and can be increased.

To inform myself better, I spent a 12-hour shift with a paramedic crew last year. Watching their performance on the front line, I was impressed by the skill with which they handled calls, and by the effort that they put into responding quickly and safely to them. They are put into a difficult position when, through no fault of their own, they turn up after a significant period of time—between 20 and 50 minutes—and have to bear the brunt of the dissatisfaction of understandably distressed relatives or patients who expected the call to be answered more quickly.

Another issue raised last year was the extent to which savings would result from a merger of the three ambulance trusts, and whether that money would be available to invest in front-line services. The Minister will be aware that deficits in the NHS were a significant issue last year. My understanding is that some of the savings from management reductions, rather than being invested in the front line, have effectively been used to plug deficits. Will the Minister comment on that?

The change undergone by the ambulance service has also had an impact on the feelings of ambulance staff, particularly in Gloucestershire. The evidence of meetings and letters, and of a blog that they have set up, suggests to me that a number of them are unhappy and disillusioned with the way in which the system is being managed. Let me share with the Minister one or two quotations from the staff blog, which, if she is interested, can be found at

One contributor to the blog recognises that

“The expected £1.6 million saving that we—

the paramedics”—

“and the public were told would be re invested into front line services, has disappeared into the PCT”


Another contributor refers to being

“Fed up with driving from one end of the county to the other”,

rushing from job to job. A particularly interesting quote relates to the matrix system of allocating resources. Its contributor says:

“We were doing so well before the matrix came along then it all went down hill like Keanu Reeves on roller skates. It’s never been any good since. Go back to the system that worked…Why do we have a two tier service? City and Town residents get a marvellous service, even the ones that like their alcohol. But live in any of the rural areas and you’re forgotten and not cared about. Waiting half an hour to an hour for an Ambulance to arrive is not acceptable so why allow it?”

Finally, a contributor to a discussion about improving ambulance response times by implementing a satellite navigation system, asks:

“So Sat Nav makes you drive 20 plus miles in under 8 minutes??”

There is a certain amount of disappointment among the staff, and that is very worrying. In an organisation undergoing significant change, where staff deliver front-line care, it is very important for management to take people with them as they introduce that change. Otherwise, the organisation will not be successful.

My constituency is a rural part of the county. My constituents pay as much in tax as people in cities and towns but get a significantly inferior service. However, they are reasonable people: they know that it is difficult to deliver certain public services in rural areas, and they understand the challenges involved. Even so, the general view is that the disparity between the provision in Gloucester and Cheltenham and the provision in my constituency is unacceptable.

On a positive note, over the first few months of this year the ambulance trust has introduced emergency care practitioners. I have talked about them before—I am due to meet some of them in my constituency next week—and it will be interesting to see whether they can help turn things around. They should enable faster response times by being based more locally in the forest.

Last week, an interesting article entitled “On the Road with New Wave Medics” appeared in my local newspaper The Forester. The reporter, Jenni Silver, found that emergency care practitioners could speed up response times, and she wrote that the presence of a practitioner

“twice…helped ambulance bosses reach their target times for Category A calls, and both times the ambulance wasn’t needed.”

The emergency care practitioners were able to assess the situation in a way that allowed better management of resources.

Obviously, I very much hope that that innovation will improve matters. The use of emergency care practitioners has only just started, so we do not yet know what effect they will have, but the article also discovered that ambulances from the Forest of Dean were

“having to wait outside Gloucestershire Royal Hospital for up to two hours to drop off patients on a Sunday.”

I accept that a Sunday is not necessarily a peak period, but the article shows that accident and emergency units at the hospital are running at capacity, and that there is little slack in the system.

The ambulance trust is also trying to use the fire and rescue service, and others, to deliver community responders. The scheme has been running for some time, and does not seem to have improved performance to any great extent. I support the idea, but my caveat is that it must be in addition to the existing service. It should not be used to replace ambulance cover where that is appropriate, and nor should it be used to massage the figures.

I turn now to performance measurement. The current system for measuring response times is misleading because it overstates, rather than understates, the ambulance trust’s performance. That may be surprising, given the appalling performance that I have outlined but, at the moment, the clock starts running when three pieces of information have been received—the nature of the complaint, the address of the patient, and a contact number.

Sometimes, all those pieces of information will not be gathered until the ambulance has arrived. Last year, there were 45 incidents in the Forest when, according to the statistics, an ambulance responded before it was recorded as having been called. The statistics may look pretty appalling, but they actually show an artificially improved reality.

Next year, the call-connect system will be introduced, with the clock starting the second that a call is received. That will lead to an immediate downturn in the statistics, but they will give a more accurate representation of the trust’s performance. Most constituents start measuring the wait for an ambulance from the minute that they get through to the call centre after dialling 999. Although the new system will provide more realistic figures, the performance will look even worse than it does at present.

It is clear that ambulance coverage in the Forest of Dean is not good enough. The matter was raised last year with the Minister and, despite the assurances, the service has gone backwards. There appeared to be some significant problems with staff being taken through the changes. My constituents deserve, from the taxes that they pay, equitable service with the rest of the county. I hope that we will experience a dramatic improvement in performance in the next year, otherwise I assure the Minister that, with the leave of Mr. Speaker, we will be back at the same time in the same place to discuss exactly the same subject next year.

I congratulate the hon. Member for Forest of Dean (Mr. Harper) on securing the debate. I do not know whether it is good or bad that the same Minister who replied last time is here again today. Obviously, I was keen to read the previous debate to ascertain what had changed between then and now so that I could provide as good a response as possible.

The hon. Gentleman raised several specific issues, which I shall try to tackle, but I shall ensure that information on some questions is provided by those responsible for the services in his area.

I pay tribute to the staff in Gloucestershire, especially the staff of the Great Western Ambulance Service NHS Trust, for the hard work they put into delivering local services. I listened carefully to the hon. Gentleman’s remarks about the comments on the blog site. Clearly, it is important to listen and I hope that those who manage services are examining the site to ascertain whether their substantial engagement is being shared and understood by those who deliver the services.

Since we last debated the matter, considerable investigation and planning of different ways in which services could be provided to deliver a better service across the piece has taken place. The specific challenges that the Forest of Dean presents have been better appreciated. Providing a better service for the future is also being considered—I shall go into that in more detail shortly.

I appreciate the hon. Gentleman’s point that some of the timings appear to have gone in the other direction since last year. However, having examined the previous debate in preparation for today’s debate, I believe that efforts have been made to tackle the problem. Although the current figures clearly need to be improved, I hope that I can give some examples that will reassure the hon. Gentleman and his constituents that the direction is now the right one.

Ambulance trusts are the first and often the most important contact for the 6 million people who call 999 each year. The range of care that they provide is clearly expanding to take health care to patients who need an emergency response, and to provide urgent advice or treatment to patients who are less ill and care to those whose condition or location prevents them from travelling easily to access health care services.

We all appreciate that the sort of services that ambulances provide—and others such as emergency care responders and community care responders—are a long way from those that were available 20 years ago. People who need treatment want it to start as soon as the ambulance arrives. They do not necessarily want to wait until they get to hospital for treatment. That is important.

Clearly, resources are also important. Spending on ambulance services has increased, with ambulance trust expenditure reaching £1.45 billion in 2005, compared with just under £620 million in 1997. That is a rise of 135 per cent., which has helped improve services.

The Government have set a standard that at least 75 per cent. of all ambulance trust 999 calls from patients with immediate life-threatening conditions should have an ambulance respond to them in eight minutes. I am pleased to tell the House that the planned resources for the Forest of Dean area for 2007-08 will mean an increase in staff from 29 to 39 full-time equivalents. There will be an increase from three ambulances working 24/7 in 2006-07 to four daytime ambulances and two night-time ambulances in 2007-08. Six emergency care practitioners will also be provided. I hope that that shows that what I said in the previous debate about planning and using resources is happening. The plans will take effect from the next financial year, despite some of the challenges posed by deficits in the area. As we know, performance has improved over recent years, but we cannot be complacent. We also know that 98 per cent. of patients are overwhelmingly satisfied with the care that they receive.

I appreciate the hon. Gentleman’s concern that response times in his constituency to immediately life-threatening calls are currently too low. The Department collects data at trust level rather than by geographical area. Ambulance trust directions issued in July 2006 required each trust to ensure that information in respect of its performance is recorded, collated and published for the trust and each of the trust's local areas. That ensures a level of not only transparency but accountability, which is important.

Our latest published figures for the trust indicate that, as at 2005-06, 74 per cent. of immediately life-threatening calls were met by the Great Western Ambulance Service NHS Trust, but as the hon. Gentleman has said, the response rate in the Forest of Dean has been low. It appears that it has gone in a slightly different direction from the lower figures that he mentioned in the previous debate. However, there are plans to raise performance across Gloucestershire to the national target levels by September this year.

I was particularly concerned, having looked at the figures for the Great Western Ambulance Service NHS Trust across the three areas—Wiltshire, Gloucestershire and Avon. The most worrying thing in the move between 2005-06 and 2006-07 is that the performance has deteriorated across category A, B and C areas. It does not seem that there is a problem just in the Forest of Dean. There is a problem across the trust in meeting its targets.

I am sure that those responsible for services in the area are mindful of that. That is why I would like to explore as part of my contribution what is taking place not just in the Forest of Dean but in the area as a whole.

The hon. Gentleman said that the new system under call-connect will give a greater sense of what is or is not happening at the most local level. Changes to clock start will be implemented from 1 April 2008. That is important. It will mean a better experience for patients, shorter waits for the phone to be answered and help to arrive and, I hope, improved outcomes, meaning more lives will be saved.

Ambulance trusts have embarked on a programme of service improvement. I understand that the Great Western Ambulance Service NHS Trust is changing its resource deployment. I mentioned earlier the increases in staff, ambulance provision and emergency care practitioners for the Forest of Dean, but of course that is being looked at across the trust as a whole.

In rural areas the trust is moving to embedding ambulance practitioners within the Community, and I am advised that the Forest now has dedicated emergency care practitioner resources in Lydney. A second scheme is due to commence later in 2007 in Cinderford. Deployment of that type of resource allows for increasing numbers of patients to be treated nearer to home, avoiding long and unnecessary journeys to hospital. It also enhances the quality of the experience for the patient. Emergency care practitioners are also able to forge closer links with local general practitioners and community health teams further to enhance emergency and urgent care in communities.

The changing model in urban areas will see increased use of ambulance practitioners as solo responders, deployed proactively to identify priority locations. That increase in solo capacity will reduce the need to utilise Forest-based resources in the urban areas. That point was of concern to the hon. Gentleman in the previous debate. I think that that has been taken on board as a way of improving and modernising services. That will support the improvement required in the Forest, as well as in the high-activity areas. That model has commenced in the past two weeks and has produced the anticipated improvement in response times, with Gloucestershire reporting over 75 per cent. for three consecutive days last week. Clearly, we cannot be complacent about those figures and we must recognise that there are still issues around the low performance rate in the Forest of Dean, but that indicates a step in the right direction.

Resources are important. To support trusts with improvements such as those, the Department made £25 million in capital available to trusts this year to enable them to fund service delivery and infrastructure changes to go further and faster in improving performance. Underpinning all that is a developing work force who are being used to the best effect, and who are at the very heart of realising true transformation in the way care is delivered.

Driving that forward requires a different blend of skills and experience. For some staff, that will involve change, but it is about recognising the changes that are necessary to deliver the best service for everyone, not forgetting that sometimes staff may need those services and will want the best for themselves as patients, as well for the patients whom they serve. But again, contributing to that draws on the creativity of front-line staff.

Community responders are clearly also a way of saving lives. New ways of working and modernisation can contribute to further improvement. Community responders are trained in basic life support and first aid and equipped with defibrillators. With emergency care practitioners, they can do more faster, and in some cases better.

In order to improve first response performance, the trust has launched two community responder schemes at Coleford and Lydney in partnership with Gloucestershire fire and rescue service. I am informed that those schemes went live on 6 December 2006. They are trained in special access techniques such as line rescue, which further enhances the joint capability within the Forest. I understand that community first responder teams have also continued to expand with a further 15 responders being trained this month. The two teams that I mentioned in my last speech have gone live in Cinderford and Newent, so I am pleased that something that I said last time round has actually happened.

The trust is also concentrating on business and leisure facilities, as well as schools, in order to embed life-saving skills and automatic external defibrillators into these environments. I am sure that the hon. Gentleman will agree that that is a good way to consider how we can differently provide better services for the future, particularly in places such as the Forest of Dean. Community defibrillation officers in the former Avon, Gloucestershire and Wiltshire area were awarded funding of £90,000 over a three-year period, and received 201 automated external defibrillators.

The reconfiguration of ambulance trusts has meant that we are in a position to start accelerating planning and delivering a better service. It will give trusts the capacity and capability to improve standards and deliver world-class services. However, delivering change on the scale that is needed takes time. NHS ambulance trusts have more money than ever before with 135 per cent. more resources than in 1997. Now that the new management teams and structures are in place I am confident that services will improve. I am sure that the hon. Gentleman will look in detail at what planning has already been provided for and what changes are already happening, and keep them under close scrutiny to ensure that they deliver the outcomes that he cares so strongly about.

The hon. Gentleman mentioned the matrix system, which also came up in our last debate. That has proved helpful, but parts of it have clearly acted against some of his concerns, particularly about rural areas. An improved computer-aided dispatch system went live today and automatic vehicle location systems will come on line in June. That will provide better real time evidence about the volume of calls and the demands on different services, which will allow the planners better to match what is needed in different parts of his trust’s area. Additional response cars have been provided in Gloucester and Cheltenham to support the matrix system and prevent resources from being constantly called out of the Forest of Dean. Again, that was a concern in our last debate, since when progress has been made, which I am pleased and reassured about.

I hope that the hon. Gentleman will agree that improvements have been made at both national and local level. The dedication and skills of ambulance staff have made that possible and their continued efforts will turn into reality the improvements that we aim to continue to deliver.

I encourage the hon. Gentleman to continue his support for his local NHS services in their commitment to deliver and maintain high quality service, and join with those who have to make the positive argument that change is not always bad. It is often for improved services and opportunities for staff to engage in a way that they may not have been allowed to do or able to do in the past.

Question put and agreed to.

Adjourned accordingly at twenty-seven minutes to Eight o’clock.