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Ambulance Resources and Response Times

Volume 580: debated on Wednesday 14 May 2014

May I begin by saying what a pleasure it is to serve again under your chairmanship, Mr Crausby? I hope that you will pass on my most grateful thanks to Mr Speaker for assisting me in securing this important debate so quickly after I made my request to him.

I also want to thank the front-line ambulance staff and paramedics whose professionalism and expertise, combined with care and compassion, can often mean the difference between life and death. Time and time again, we hear of the dedication beyond the call of duty of front-line staff in the NHS, and it is entirely right that we hold them in high regard and give them the recognition, remuneration and resources to do their job.

This debate was prompted by the tragic circumstances surrounding the death of one of my constituents, Mr William Gouldburn. Mr Gouldburn was 73 and had served his community as a special needs teacher. He had heart problems, and in the previous couple of days he had come out of hospital after surgery to his shoulder. After leaving hospital, he had felt unwell, to the extent that a doctor was called to his home at 9 am. Less than 90 minutes later, Mr Gouldburn collapsed in his bedroom and an ambulance was called by 10.32 am. The call was not considered to be urgent by the contact centre that took it, and a response time of 60 minutes was given. However, even that response time was not met. It was after 12 noon that a St John Ambulance arrived.

My understanding is that Mr Gouldburn’s family, who were naturally frantic about his condition, placed a total of seven calls about his case to the emergency services during this period. At this point he was lying on the floor of his bathroom, and he was to do so for more than 90 minutes. A regular ambulance was eventually dispatched, but Mr Gouldburn was pronounced dead shortly afterwards. I hope that the whole House will join me in sending condolences to Mr Gouldburn’s family.

At the inquest into Mr Gouldburn’s death last month, a manager for the North East Ambulance Service said that the service had been experiencing a high level of calls and that ambulances were delayed in admitting patients to North Durham hospital due to a lack of available beds. The manager was asked by the coroner:

“Is what I’m hearing you don’t have resources to meet demand?”

The ambulance service manager stated:

“Yes, that’s correct. It is a national problem”.

Mr Gouldburn’s case raises some significant questions about ambulance services, which is why I wanted to secure this debate.

I am grateful to my hon. Friend for giving way and I congratulate him on securing this important and timely debate. There are serious concerns about the performance of the ambulance service in the north-east region. What is his opinion of the assessment by its chief executive, Simon Featherstone, that the service’s unsatisfactory performance is not as a result of the cuts, given that the trust is having to make £23 million of cuts during the lifetime of this Parliament?

I must praise my hon. Friend, because he does fantastic work on health issues through his passionate commitment to the NHS and in his work on the Select Committee on Health. He is absolutely right, and I will come on to the finances and resources for ambulance services in a moment.

Mr Gouldburn’s case was tragic, and from what the coroner said, it was avoidable. However, a further tragedy is that his case is not unique or isolated. I have been told about similar cases, as my hon. Friends have been.

I commend my hon. Friend for securing this debate so quickly. I have raised the issue of the NEAS a number of times. I have met the Minister about it; I even recognise some of the civil servants who are here today, having met them before. However, I was talking then about cases in the dales, where we accept that there will be an issue about logistics. Recently, cases have been raised with me every week. The latest one involved an elderly lady who fell outside and broke her hip. When her son rang to find out where the ambulance was, he was told that she was 42nd in the queue. She was lying outside with a broken hip for three hours, and that happened in Consett, where there is an ambulance service in the town. The whole situation is spiralling out of control, and I would welcome my hon. Friend’s views on it.

My hon. Friend is absolutely right that the situation is spiralling out of control. The case that she has just told the House about is simply unacceptable and downright distressing, but it is not unique.

My hon. Friend is being very generous in giving way, and I congratulate him on securing this debate. I concur, of course, with what he has said in praise of front-line ambulance staff, and I also express my condolences to the family of his constituent.

The South Central Ambulance Service, which has a good record against targets in urban areas but a less good record in rural areas, has faced rising demand as well. One of the specific factors that it has pointed to is the increasing number of referrals it receives from the 111 service. Is that also a factor in my hon. Friend’s area?

It could have been a factor in Mr Gouldburn’s case, because originally his family contacted the ambulance service via 999 but subsequently they went to 111. I do not think that there is sufficient join-up between the ambulance services and the contact centres about what is appropriate to 999 and what is appropriate to 111. I hope that the Minister will respond to that point.

The hon. Gentleman is being very kind and gracious in giving way, although I had asked his permission to intervene beforehand.

Obviously I do not represent the immediate area covered by the ambulance service that the hon. Gentleman is referring to. In Northern Ireland, however, we have a system whereby the ambulance service can respond to someone who has had a heart attack, as was the case with his constituent. It is a rapid response unit, whereby a car goes out in advance of the ambulance and staff take the urgent remedial and medical action that is necessary in the critical first minutes after what has happened, and then the ambulance follows. Does he feel that the Minister could consider using that system in parts of England as well?

We should have that system already, but it is simply not working in the north-east and in other parts.

Let me cite another case. A constituent of mine from the Headland part of Hartlepool, which is an urban area, contacted me to say:

“My dad has kidney failure and has only 12% of his kidneys working. Just over three weeks ago, my mam rang me concerned about dad. When I arrived at their house, I could see he was very, very ill. I rang immediately for an ambulance. A nurse rang me back for an assessment of dad. No ambulance. I rang again, another assessment, no ambulance. I rang again, another assessment, (the 4th one), this time stressing that I was angry because he was dying and the family would be driving dad to the hospital if they didn’t come, even though this was impossible. After two hours ten minutes, the ambulance finally arrived. In each phone call that I made, I stressed the fact that dad had kidney failure, which results in potassium build up, which results in a heart attack.”

Thankfully, my constituent’s father went to hospital and, almost against the odds, is slowly improving. As my constituent stated to me:

“He is still weak but my dad has always been a hard worker and a tough, strong man. He is at home but missing going to his allotment! There is no doubt the wonderful nurses and doctors saved dad’s life.”

I want the Minister to respond to and take action on a number of points raised by the examples that I and my hon. Friends have given. First and foremost is that stark admission from a manager within the NEAS that the service does not have the resources to meet demand, and that that is a national problem. As my right hon. Friend the Member for Oxford East (Mr Smith) said, demand is clearly rising. Since the 2010 general election, emergency calls to ambulance services in England have increased by about 12%, and calls in the north-east have gone up by about 13%. An ageing population will only increase demand further. In the next decade, this country will need more ambulance resources, not less.

My hon. Friend has secured an excellent debate. We know from the NEAS itself that it had an expectation of 415,000 call-outs in the financial year 2012-13, yet it was funded for only 376,000 calls. Also, the use of private ambulances has gone up ninefold, with an initial cost of £96,000 in 2009-10 rising to £754,461 in 2012-13.

I know that my hon. Friend has spoken in the House about this issue before, and I praise him for that. The use of private ambulances is taking resources away from our having a sustainable public service, which all our constituents want. As a result of that, the ambulance services are not able to invest in their work force, and something needs to be done about it. I hope that the Minister will respond directly to my hon. Friend about that issue, because the use of private ambulances is simply unacceptable.

I am grateful to my hon. Friend for giving way again. As this is a 30-minute debate, I will keep my interventions short, although I have a whole list of constituents who have waited an inordinate length of time; there is not the opportunity in a short debate, such as this one, to give all those examples.

In relation to the specific point about private ambulances, is it possible that the Government’s health reforms have led to fragmentation? I ask that because I have met representatives of front-line ambulance staff who have told me that the one-year contracts from the clinical commissioning group are not helping with the North East Ambulance Service NHS Trust’s forward planning of the services and resources that are needed to meet local demand.

My hon. Friend makes an important point. How can an ambulance service plan for the next five years if it faces annual commissioning rounds? That does not work and does not provide long-term sustainability.

The North East Ambulance Service, which, like other ambulance services, has received a flat cash offer from the Government over the course of this Parliament, has been required to cut £4.83 million from its budget for 2012-13, which is some 5% in real terms, and another £4.35 million for 2013-14. Unison estimates that real cuts of about 20% to 25% have been made to ambulance services so far over this Parliament. Those cuts, coupled with rising demand, are having a detrimental impact on the quality of ambulance service that people receive.

If the hon. Lady will allow me to continue for a moment, what I am about to say is relevant to her area. Response times, especially for the most life-threatening emergency cases, are getting worse. In March 2012, 75.5% of emergency calls in England were responded to within eight minutes. In March 2014, in the latest figures available, that had gone down to 74.7%, with seven of the 11 ambulance trusts, including the North East Ambulance Service, seeing a deterioration in performance. The East of England Ambulance Service saw the proportion of emergency calls responded to within eight minutes fall from 76.2% to 62.4%. That is simply unacceptable, and the hon. Lady will want to respond to it.

I congratulate the hon. Gentleman on securing the debate. I agree that this is a depressingly familiar situation, but I do praise Anthony Marsh, the new chief executive of the East of England Ambulance Service. I recognise the hon. Gentleman’s points, but what is the North East Ambulance Service’s board doing? MPs in the east of England campaigned and successfully managed to get rid of the entire board.

As a north-east collective, we work closely to ensure that our constituents get the best possible services.

Let me move on to average response times. In the north-east, the average response time increased from five minutes and 16 seconds in 2011 to five minutes and 48 seconds last year. The east of England saw a 90-second increase in response times. Only one ambulance trust actually reduced the average emergency response time. Those figures reinforce what the senior management from the North East Ambulance Service confirmed at Mr Gouldburn’s inquest, namely that ambulance services do not have the resources to meet demand, that it is a national problem and that response times are suffering as a result. There has been an admission from a senior manager in the ambulance service that resources are not keeping up with demand. Response times, in particular for more serous cases, are deteriorating and lives are being threatened, if not tragically lost. Will the Minister therefore pledge this afternoon to provide more resources to ambulance services in Hartlepool, the north-east and across England to meet rising demand?

I also want to question the assessment process used to screen calls and prioritise response times. Given Mr Gouldburn’s history of heart problems, his age and the fact that he had recently undergone surgery and had seen the doctor that same day, why on earth was he not prioritised as an emergency case and provided with an eight-minute response time? Why did it take seven calls to escalate the case to an emergency? The Minister must accept that that is simply unacceptable. Is there pressure from the Government to downgrade the priority of emergency calls due to inadequate resources?

This week, I received a letter from the Health Minister Earl Howe stating in response to Mr Gouldburn’s case that

“the 999 call was triaged correctly, although some of the questioning could have been better.”

Why was it not better? Why is the questioning not relevant and efficient in every case? The constituent whose father had kidney problems said to me:

“Phone assessments should be changed. In each assessment they asked me did dad have a rash and could he put his chin on his chest! Words like kidney failure and potassium should be taken note of. Because I’m not a rude person I didn’t react angrily, but wish I had because dad could have died. We realise that there is a shortage of ambulances and this can’t go on. We are a rich country. Shortages of ambulances are something you read about in poor countries. It shouldn’t be happening here.”

Assessment and prioritisation seem to be failing and the right questions are not being asked during initial screening. What will the Minister do to address that?

The third issue is that ambulances were delayed because of a problem in admitting patients to North Durham hospital due to a lack of available beds. That seems to show both a lack of joined-up thinking on hospital admissions and the fact that ambulance and NHS resources are hanging by a thread. Is it really acceptable, as seems to have happened in Mr Gouldburn’s case, that because of a delay at a single hospital in County Durham due to insufficient beds, the whole ambulance service for the north-east, or certainly the south of the region, grinds to a halt? The Minister surely cannot find that acceptable. Are resources being spread so thinly that services are not being provided to my constituents?

Hospital services in my area have gone through dramatic changes in the past few years, as my hon. Friend the Member for Easington (Grahame M. Morris) knows all too well. Hartlepool’s A and E closed in August 2011, much to the town’s concern, on the grounds of clinical safety and the specialisation and centralisation of appropriate medical skills. There is a mismatch between the Momentum programme of centralising services and the Government’s failure either to commit to funding a new hospital or to provide resources to reinstate services at the existing Hartlepool hospital. If there are fewer A and Es across the country and ambulances have to travel greater distances to a smaller number of centres, will that not increase the handover and turnaround times of patients between the ambulance service and hospital staff? Ambulance crews—my hon. Friend the Member for Middlesbrough South and East Cleveland (Tom Blenkinsop) has been strong on this—are queuing up outside fewer hospitals, making handover and turnaround times worse. Does that not reduce the amount of time for which ambulance staff can be in a position to respond to emergency calls?

Such cases will only increase in my constituency, where it is proposed to close two minor injury units and the walk-in centre in Skelton. That all comes on the back of a recent development at the South Tees Hospitals NHS Foundation Trust, which could have a £50 million deficit. My main problem is that we have been refused meetings with Health Ministers to discuss such matters.

It is wrong for any Minister to refuse a meeting request from a Member of Parliament, in particular on something as important as ambulance response and handover times.

Will the Minister respond to my point about the trade-off between the specialisation and centralisation of services, which is how the NHS is going, and the impact on the distances travelled by ambulances and their subsequent response and return-to-road times? Those are links in the chain that will ensure a seamless and high-quality NHS service, but they do not seem to be as locked together as they should. What is the Minister doing to address that? Will she commit to monitoring handover times to ensure a better and more responsive service for all patients?

At times of emergency and crisis for themselves or their loved ones, the public expect a responsive and professional ambulance service, but as we have heard from those working at a senior level within the North East Ambulance Service, resources are not matching demand, response times are worsening and lives are being threatened. Will the Minister act to ensure that in Hartlepool, the north-east and across the country we have ambulance provision that meets demands, is professional and is the best in the world?

I congratulate the hon. Member for Hartlepool (Mr Wright) on securing the debate. Given the wide range of topics that he and his colleagues raised, I am not sure whether I will be able to cover them all in the time available, so if I do not, I will attempt to respond to any substantive points after the debate. I will also certainly alert my noble Friend Earl Howe to the points made.

As the hon. Gentleman said, ambulance services are vital to the health care system and provide rapid assistance to people in urgent need of help. Many lives are saved by the hard work of ambulance service personnel. He is right to place his congratulations on the record and I want to place on the record my appreciation of the work done by staff in ambulance trusts. I gently suggest that I do not recognise some of the words and phrases used in the debate to characterise the service provided, but I am sure that they were used to stress a point.

No, because I have only just begun and the hon. Gentleman took many interventions.

Emergency services are the first port of call for many of us when serious illness or accident strikes. The total number of emergency calls to ambulance services in England in 2013-14 was 8.4 million, which is a 0.9% drop over the previous year. Unfortunately, a small proportion are unnecessary or frivolous, but the overwhelming majority are from people who feel in need of urgent help.

The growing number of people living with chronic conditions and the ageing population to which the hon. Gentleman referred are placing increasing pressure on urgent care services, something that we all acknowledge. It is important for my Department to work with Public Health England, local commissioners and health care providers to educate and engage the public on measures to prevent chronic health problems from developing. There are a number of people who end up in A and E because they have not taken medication properly or who suffer acute problems as a result of a chronic condition. Hon. Members will be aware of some of the longer-term problems in their region, which result from difficult public health challenges. Tackling those is my own particular portfolio, and is one way in which we can make the emergency services more sustainable in the longer term.

I hope hon. Members recognise that. At times, it seemed that they were merely committing themselves to significant additional future spending rather than also turning their minds to the longer-term challenges.

I am going to continue and try to make a few substantive points. If I have time, I will give way.

All 999 calls are triaged into two basic categories, red and green, depending on the seriousness of the call. Those placed in the red category are calls where the patient is in a life-threatening condition; an example would be someone suffering a cardiac arrest. Such calls require assistance on the scene as quickly as possible and the Government have set targets for all ambulance services in England of a response within eight minutes in 75% of cases. The latest figures, for March 2014, show that in north-east England—the area of the hon. Member for Hartlepool—the median average response time for red category calls was 6.4 minutes. Nationally, those figures show that 76.2% of red 1 calls, which are the most critical, received a response within eight minutes. In the north-east the target was also met, with 75.2% of patients receiving a response within eight minutes. That is not to say that there are not significant problems in some cases, but it is important to place on the record the service’s effective work in meeting that target.

Less critical 999 calls placed are in the green category. Those calls are not subject to national targets. Some ambulance services set their own targets for response times, and NEAS uses a one hour standard. It is important that such calls receive a timely and appropriate response, but red calls must be prioritised, as a person’s life may be in immediate danger.

There has been recent media coverage of long waits for ambulances, and hon. Members have alluded to constituents’ experience of such waits during this short debate. Every patient should expect to receive first-class care from the ambulance service, but the nature of emergency response work means there will always be incidents where unfortunate timing leads to a situation in which someone who is assessed as being in a non-life-threatening situation calls 999 at the same time as several other people who are in life-threatening situations. I am sure that hon. Members recognise that that would be the case under any Administration.

I am grateful to the Minister for giving way, but I cannot let that pass, because the situation is different now. I have had the honour of representing Easington for four years and it is evident from the cases that are coming to me and to colleagues from the region that the situation is worsening. One case was that of a young man who broke his hip playing football and waited for two and a half hours in the rain. He was in the centre of the constituency, in an area that is readily accessible. Another was of an old lady who waited two and a half hours for an ambulance. She died the following day. Something is sadly wrong with the North East Ambulance Service and the situation is deteriorating. We have all had cases that are really quite shocking, and something needs to be done.

I am not familiar with the cases that the hon. Gentleman mentioned, but I will draw them to the attention of my ministerial colleagues and of the trust. I spoke to the head of the trust yesterday, and will make sure that the debate is brought to the trust’s attention. However, I gently say to hon. Members that they surely cannot be suggesting that at no previous time, under any previous Government, have there been any cases in which a service did not get this right. It is important to—

I do not recognise that description, and I do not think the service would recognise it.

Very rarely, as we have heard, waits may be unacceptably long, but it is important to remember that the vast majority of people receive a timely response when they dial 999. I am aware of the case of William Gouldburn, who was the constituent of the hon. Member for Hartlepool and who sadly died in April last year as the result of an existing heart condition. He waited two hours for an ambulance after his collapse at home. His case is distressing, and his MP is right to champion it and make us aware of it. The trust acknowledges that it failed by not getting an ambulance to Mr Gouldburn within the one-hour target it had set itself. It has been accepted that that was not good enough.

Difficult as his story is to hear, it is important to note that Mr Gouldburn’s 999 call was categorised as a green call—that is, a non-life-threatening situation—and at the inquest the coroner accepted that the call had been correctly triaged and categorised. That is not to say that there were not things that clearly should have been done differently, but it is right to put on the record what the coroner said. There is no denying that Mr Gouldburn waited an unacceptably long time for an ambulance, but the decision on his call’s priority was made when other calls were at the same time being prioritised as red.

It is a matter for local commissioners to agree with ambulance trusts the appropriate protocols for dealing with green calls, based on available clinical guidelines and local circumstances. I know that in the case of the hon. Member for North West Durham (Pat Glass) those local circumstances have been recognised with the introduction of a specific response vehicle in her constituency. There has been increasing demand on ambulance services—the North East Ambulance Service says that it saw a 5% increase in the volume of emergency incidents in the year up to March 2014—but thanks to the hard work of service staff, fast response times have been delivered in the vast majority of cases.

NEAS advises that over 40% of the calls it receives are categorised as red, so its consistent ability to exceed the national target for response times should be commended. NEAS has also told me that in 2013-14, 74.8% of calls categorised as green 2, or serious but not life-threatening, received a response within 30 minutes.

Sitting suspended for a Division in the House.

On resuming—

Thank you, Mr Crausby. Welcome back to the hon. Member for Hartlepool—I think some colleagues may not have been able to rejoin us.

As I was saying, NEAS tells me that in 2013-14, 74.8% of calls categorised as green 2, meaning serious but not life-threatening, received a response within 30 minutes, and 71.2% of calls categorised as green 3, meaning non-emergency, received a response within 60 minutes. Although that does not in any way diminish the tragedy of cases such as Mr Gouldburn’s, which are never acceptable, it is important that we recognise the generally excellent service provided by the trust and its staff.

I appreciate what the Minister is saying, but when it goes bad, it goes catastrophically bad, with life-threatening consequences. Surely she realises that we should make sure that we minimise that as much as possible.

I think we can all agree that those are circumstances that we want to minimise.

I want to turn briefly to one or two specific local points, and then to one or two wider points. Most recently, the Government recognised the importance of investment in front-line services with £14 million provided to ambulance services last December. Obviously, it is for local commissioners and trusts to decide how that money is used. I recognise that in the hon. Gentleman’s region, local commissioners see that more investment is needed for ambulance services, and we recognise that the trusts are working with local commissioners on that, making sure that they get that commissioning piece right.

More generally, there is also an issue about staffing in the ambulance service. Since 2010, the NHS has recruited 16% more paramedics, but we know that in some areas of the country, there is insufficient academic capacity, for example, to produce paramedics in the numbers required. Again, the Association of Ambulance Chief Executives is working with Health Education England to address that issue in the medium term.

The hon. Gentleman also alluded to ambulance handover delays. We absolutely recognise the role that they can play in making the job of the ambulance service more difficult. I believe there has been an ongoing issue, to which he alluded, for NEAS at County Durham and Darlington NHS Foundation Trust hospitals. Local commissioners have advised that there has been recent improvement, helped by winter initiatives supported by the urgent care working group. That has included support from the fire and police service, but I know there is more to be done.

Indeed, my colleague from the east of England, my hon. Friend the Member for Suffolk Coastal (Dr Coffey), who has not been able to rejoin us, was talking as we went to the vote about work that had been done specifically in her area to look at some particular issues that affect handover delay. As she said in her intervention on the hon. Gentleman, it is well worth local Members exploring some of that detail with their board as well to see whether lessons can be learnt from other parts of the country.

The urgent and emergency care review is being led by Sir Bruce Keogh, the national medical director of NHS England. He was asked to undertake a review of urgent and emergency care, looking at all aspects of the sustainability of the urgent and emergency care system. That does not exclude ambulance services. The review proposes the development of 999 ambulances; they would become more like mobile treatment services, not just urgent transport vehicles. There is a lot of fresh thinking in all sorts of areas of delivering excellence in emergency health care, and it is right that we look at new ways of delivering that health care with regard to ambulances as well, rather than just looking at the old model.

I want briefly to put a point on the record in the 30 seconds left to me. Let us not minimise the importance of people being asked about a rash as a symptom on the phone. It is one of the signs of meningitis and the royal colleges have advised that that should be asked as a question, so it is not an insignificant point.

With regard to private ambulances, that provision was brought in by the right hon. Member for Leigh (Andy Burnham), when he was in office—

Sitting adjourned without Question put (Standing Order No. 10(13)).