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House of Commons Hansard
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East Midlands Ambulance Service
21 February 2018
Volume 636

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I beg to move,

That this House has considered the performance of East Midlands ambulance service.

It is a pleasure to serve under your chairmanship, Mr Davies. The ambulance service is the glue that holds our health service together, and it does an incredible job. I have heard some harrowing examples in recent weeks of ambulance waits, but I want to start by putting that into context. Last October, my constituent Vinnie fell down stairs in the early hours and hit his head so hard that his heart stopped. The 999 call handler talked Vinnie’s partner Jo through cardiopulmonary resuscitation to keep him alive until the ambulance arrived 15 minutes later. That crew literally saved his life. Vinnie and Jo want to say thank you to those people, but they do not know their names. On behalf of Vinnie and Jo and everyone for whom our ambulance services have done amazing things, thank you.

Ambulance crews do amazing things every day, but they are struggling, especially in the east midlands. Our response times have consistently been below the average and near the bottom of the regional tables. In January, the east midlands came ninth out of the 10 regions in responses to category 1, 2 and 3 calls. On category 2 emergency calls, which have a target average response time of 18 minutes, East Midlands ambulance’s average was 37 minutes—more than twice as long.

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We used to have a Lincolnshire ambulance service, which I thought provided a very good service, but we were told that the way to get a better service was to regionalise and effectively centralise. We now find that many ambulances are taken off to Leicestershire or Nottinghamshire—no doubt for a good cause—and they do not come back to Lincolnshire. Does that not underline the need for localism and local services run by local people?

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To be honest, when I was at East Midlands ambulance HQ, the waiting time at Lincoln hospital was seven hours for patient handover. Unfortunately, in those situations ambulances are diverted to where patients who need help urgently can get the care they need. Part of the problem is the handover times, particularly at Lincoln.

The longest 10% of urgent responses took more than 82 minutes, which is twice the target of 40 minutes. For category 3 urgent calls, 10% of East Midland’s calls took more than three hours 22 minutes against a target of two hours. In practice, that means that people who are very seriously ill or in pain are waiting hours and hours for an ambulance. My constituent, Debbie, contacted me on Saturday night at 10 o’clock. Her 82-year-old mum had a hairline fracture of her hip. It had not been diagnosed, and suddenly her mum found herself in excruciating pain and unable to move. Despite calls to 111 and then 999, there was simply no ambulance available.

It was only when Debbie called at midnight and said that her mum was passing out of consciousness due to exhaustion and pain that the call was upgraded to category 2 and the ambulance arrived 20 minutes later. By then her mum had been waiting in agony for more than nine hours. The ambulance crew apologised, but they had been on more urgent calls the whole time. Debbie and many other constituents have contacted me to ask, “Why is this happening?”

A few weeks ago, I visited the ambulance control centre at Nottingham to see the management of East Midlands ambulance calls across the whole region. It was a Friday lunchtime, but even at that time the emergency calls and urgent calls were stacking up. I listened in as people were calling back to find out how long an ambulance would take. Health professionals, families, neighbours and shop assistants were all caring for someone who was seriously ill and needed an ambulance. They were undergoing hours of pain, worry and uncertainty.

From that experience and from speaking to local paramedics and East Midlands ambulance managers, it seems that there are four key reasons for the issues. The first is our geography. East Midlands ambulance covers a huge area, from the border of Manchester in my constituency to the shores of Lincolnshire. It has the second lowest population density in England after the south-west, but also the second-lowest investment in transport infrastructure after the north-east. It is not only a large region; it is hard to get around.

Secondly, when ambulances do get their patient to hospital, they encounter some of the longest waits for transfers. In 2015-16—the latest figures that we can obtain—only 44% of handovers in the east midlands were completed within 15 minutes, compared with 58%, on average, across England. This winter, handover times in some hospitals have got much worse. At my constituents’ local A&E at Stepping Hill, ambulances were waiting for more than three hours. At Lincoln hospital, it was more than seven hours. When vulnerable people are waiting in severe pain for an ambulance, to have them queued up outside hospitals unable to hand over their patients is incredibly frustrating.

The third issue is the level of demand. In the east midlands, the number of responses rose from 222,000 in 2011-12, to 335,000 in 2016-17—an increase of more than 50%.

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I thank EMAS for coming to meet with the northern Lincolnshire and Lincolnshire group of MPs last year, when we were concerned about ambulance provision. Subsequent to that, paramedic Lee Hastie gave an account to the local Grimsby Telegraph about his experiences, particularly in relation to demand for ambulance services, saying that most of his calls on an everyday basis now relate to drug and alcohol abuse. Does my hon. Friend consider that cuts to local government drug and alcohol services have gone some way to increasing the demand on our ambulance services? They are essential services that, at a community level, simply are not there any longer.

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I would certainly concur with that statement. It is one of many areas in which the lack of services at an urgent level is creating an increased demand—but in no way has East Midlands ambulance service’s funding increased to cover that level of demand, as we will see later.

Part of the increase is due to the 111 service. We saw the chaos that 111 created when the coalition Government brought it in to replace Labour’s NHS Direct with a much cheaper service with hardly any clinicians. Things have improved, but at busy times the 111 service still does not have enough qualified staff to make decisions, so the call-handlers have to be risk-averse, follow their script, and call out an ambulance if there is any doubt at all.

We have seen the number of 111 calls resulting in an ambulance call-out gradually increase from 100,000 in 2011-12 to 1.3 million across England in 2015-16. That is almost 14% of all ambulance call-outs going to people who did not request an ambulance in the first place—people such as my constituent Gemma. She suffered abdominal pain and called 111 for an out-of-hours doctor to come and see her. Even though Gemma told the call-handler that if she needed to get to hospital she would drive herself there, they still sent an ambulance to her. Gemma was diagnosed with gallstones, and next time she had an incident and needed pain relief urgently she again called 111 to tell them that she knew what the problem was and to ask for a prescription. Instead, they again insisted on an ambulance and would not accept a refusal. Gemma actually drove herself to A&E because she was so determined not to use ambulance time.

The ambulance service says that it is not allowed to reassess 111 calls that have been allocated for an ambulance response, so even if it expects that it is not necessary, it cannot use its expert clinicians to provide the telephone advice and decide whether an ambulance is really necessary. I will get on to the question of resources shortly, but besides resources, my local paramedics have asked whether the ambulance service can reassess 111 calls that it is given if it is in any doubt. I put that question, from them, to the Minister.

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I thank my hon. Friend for the very strong case that she is making; she is an outstanding campaigner for our region. Nottingham city MPs are very concerned about this issue; I am the only one present because my two colleagues are on other parliamentary business. We would like to see real evidence of the provider coming together with unions, clinicians and service users to try to iron out some of the issues that my hon. Friend is talking about. Does she agree that that would perhaps be a good way to manage better the resources that we have?

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We can always seek to manage resources better, but East Midlands ambulance service has been seeking to manage resources for a very long time, working with Unison and the unions there.

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Does my hon. Friend agree that the closure of Lincoln’s walk-in centre, despite the fact that 94% of the people who responded to the consultation said that they did not want it to close, cannot fail to have a further impact on EMAS and local services? We are told by the clinical commissioning group that it will not have an impact and that there will be other provision, but the local ambulance teams—I will come to this point when I give my speech—told me that it will absolutely have an impact. I wonder what her thoughts are on that.

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Walk-in centres were established by the last Labour Government to reduce the demand on the ambulance services and to give people the services that they actually needed on their doorstep. Every cut of every walk-in centre is hugely worrying, both for patients and the ambulance service.

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Demographically, patients attending A&E, which treats accidents and emergencies, not anything and everything, are the very sickest patients, or those patients requiring treatment such as X-rays that cannot be delivered in centres such as a general practice. The review into the walk-in centre, as I understand it, and as it has been explained to me, was actually done by clinicians rather than politicians. The clinicians are telling us that it will not have an effect because, demographically, the patients going to the walk-in centre are those who are relatively well. If the walk-in centre was closed, they would be making their own way to the hospital, a general practice or a pharmacy, rather than calling 999.

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The fact is that walk-in centres are open late in the evenings and at weekends, and in most GP practices it is not possible to get an urgent appointment without phoning at 8 am exactly. In my constituency, people have to wait at least two weeks to get an appointment.

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When I went out with the ambulance team, one of the people who called and got an ambulance was an elderly gentleman of 91 who had breathing problems. He called an ambulance because he could not get a GP appointment or get to the walk-in centre at that point. It is not always people who are desperately ill who call ambulances; lots of people call ambulances in sheer desperation because they cannot get anything else.

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That illustrates the point completely. We have seen a lack of primary care services, and doctors’ appointments are far harder to get than the 48 hours it took under a Labour Government. In consequence, we have a hugely overburdened ambulance service.

Now we come to funding. East Midlands ambulance service is already one of the most efficient in all the regions. In spite of the relatively sparse population and demanding geography, EMAS’s costs per face-to-face response are the third-lowest of all the regions—9% lower than the average across England. The costs per call are, again, the third lowest and more than 10% below the average.

By any measure, East Midlands ambulance service is very efficient, with 99% of its staff working on the frontline. Almost all managers take shifts so that they know exactly what is going on. It has cut all that it can, and it has had to make cuts, because EMAS has the second-lowest funding of all the regions—8% lower than the average across England. Only the North East ambulance service, which serves a more densely populated area, has lower funding than the East Midlands ambulance service.

The funding has not kept pace either with inflation or with the increased demand—in fact, it has barely increased at all in the last six years. In 2010-11, EMAS received £160 million for patient care activities. By 2016-17, we had seen over 16% inflation and a 50% increase in activity. Funding should be at least two thirds higher—£105 million extra would be the proportionate cost. Instead, East Midlands ambulance service received less than £5 million extra compared with 2011. That is less than 3% extra funding when it needed 66%.

East Midlands ambulance service has never been well funded—our region has always been the poor relation, as colleagues on both sides of the House often concur—but the cuts over the last seven years have made it impossible for it to meet its targets, and to deliver the right standard of service and care to some of the most sick and injured people, and the most at risk. That is what the Nottinghamshire coroner concluded in May 2016. In an urgent case review, she said:

“Demand is clearly greater than the resources they have most of the time”.

That is not the fault of any of the staff at EMAS. Last summer, the Care Quality Commission found that although the service was in need of improvement, it was caring and responsive—but it could not be safe or effective. The report states that there were

“caring, professional staff delivering compassionate, patient focussed care in circumstances that were challenging due to the continued demand placed on the service.”

The increased demand for primary care, emergency care and ambulance services is not being resourced. Our ambulance service is on the frontline. Our crews do their very best, but it is tough. Yes, staff sickness is slightly higher than average at EMAS, but I am not surprised. It is not just what the crews deal with; it is the constant stress and pressure, and the distress and anger that they sometimes face when they can finally arrive.

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The hon. Lady is making a very articulate and compelling case, but I think she would be the first to acknowledge that, while there may well be a resource challenge of the kind she described—she has already made that clear—there are issues around administration, management, process and protocols. She has already mentioned ambulances waiting outside hospitals for a very long time because they cannot or will not admit patients. Those are systemic problems, not just resource problems.

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It might not be a resource problem at EMAS, although EMAS has been trying to fix that with staff put on especially to try to reduce the handover times at hospitals. A&E departments are struggling at absolute capacity. My local hospital had 97 A&E patients in need of a bed last weekend, and they had seven beds. The fact that the number of beds in the NHS has been reduced by 14,000 since 2010 is a resource issue. It might not be an EMAS issue, but it is very much a resource issue, and I put that to the Minister along with the issue of EMAS.

The situation is not fair on our ambulance crews. It is not fair on our patients. Our ambulance service is holding emergency care together. East Midlands is doing it with more pressure and less resources than almost anywhere else in the country. It needs support from us and it needs the resources to meet its targets. I call on the Minister to commit to that today.

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Order. Five people want to speak, so I am going to impose a time limit of five minutes so that there is enough time for wind-ups. I call Dr Caroline Johnson.

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It is a pleasure to serve under your chairmanship, Mr Davies. I thank the hon. Member for High Peak (Ruth George) for securing this debate, on an issue that is incredibly important to her, to me, and to all of our constituents. As a children’s doctor, I have been required to deliver full intensive care to children, particularly babies, who are being transferred in East Midlands ambulance service ambulances through the night, through the day, hurtling along in the back of the ambulance as it travels on our rural country roads, round corners and down the hard shoulders of motorways at great speed, so I understand some of what they do. It has given me a deep appreciation of the work of ambulance crews and has also highlighted to me the unique challenges and pressures that they face, particularly in our rural areas.

My constituency of Sleaford and North Hykeham in north Lincolnshire has a dispersed population, a rural road network and some NHS staffing challenges, all of which have contributed to the ambulance service failing to meet its national targets. As the overnight closure of Grantham A&E, which is just adjacent to my constituency, requires ambulances to now travel greater distances to Boston, Nottingham and Lincoln, every few weeks I receive a letter from a constituent who has waited an unacceptable amount of time for an ambulance. Indeed, I myself, as a member of the public, have been at the side of the road trying my best to treat casualties, waiting a long time for an ambulance. One gentleman died, although it is likely that that would have been the case anyway.

There is no quick fix to improving ambulance response times in rural areas. It is easy to identify and talk about the problem, but we also need to talk about potential solutions. One example would be the effective cohorting of patients when they arrive in A&E to allow ambulance crews to get back on the road sooner.

We have heard about the problems faced by ambulance crews waiting a long time to hand over in A&E, and it is right and proper that the care of patients is properly handed over before the ambulance crew leave, but it is worth noting that when a crew is with a patient, that patient is effectively receiving two-to-one care. I appreciate that paramedics and nurses have different skills, but that is higher than the dependency level provided for intensive care, where there is a one nurse to one patient ratio. Many of those patients, since they are waiting in corridors—unacceptably, I would say—are at the lower level of dependency as compared with the patient that has been taken straight into resus and received immediate treatment. So when three consecutive ambulance crews come in with three patients, there are six members of staff caring for them, and that is not necessary. One crew could care for them while the other two crews go out and see patients.

It is also worth noting that the patient who is at home is at a greater level of risk than the patient in the hospital. In the circumstance I have described, we have six ambulance crew looking after three patients in a hospital. The patients are of moderate ill health—they need to be in hospital and need to be seen, but they do not need to go into resus right at this moment. Equally, they are at a lower level of risk than the person sat in their home in a rural area of my constituency, say in Nocton, waiting for an ambulance to come, who has no access to medical care at all. If the person at home deteriorates, they cannot be wheeled round the corner immediately into resus, while being continually observed by a paramedic in the meantime.

Following my work in A&E over the Christmas period—I still practice as a paediatrician—I met the Secretary of State for Health and Social Care to discuss that point. I understand he and the civil service are looking at it, and I would be grateful for an update from the Minister on how that work is progressing. I believe that it would improve not just patient care but also the ambulance response times in the community.

The second issue I want to talk about is the type of ambulance crew. Many people are of the view that when an ambulance crew arrives, it contains the same level of skill mix, regardless of which ambulance comes, but that is actually not the case. There are highly trained specialist technicians and there are paramedics, who have additional levels of skill. There can be situations where, because we need to direct the correct crew to the correct problem—for example a particularly ill patient might need a paramedic and another patient might need a technician—there might be two crews near two patients going in opposite directions, taking longer to get to somebody. That is because they are not all paramedic crew. Although that probably makes little or no difference to response times in a city centre, in a rural area, where response times will always be longer because of the geography involved, we should increase the number of paramedics, perhaps having all paramedic crews. If we were in a position where all crews were paramedic crews, an ambulance would always go to the nearest casualty and not necessarily the matched one, which would improve response times. In addition, we can increase the number of patients who receive care en route.

We hear a lot about the golden hour—patients that need treatment within that first hour of care. If they get treatment in that first hour, we know they get better outcomes in the long term. If we are sending a technician crew who are perhaps not able to provide some of the treatments that a paramedic crew can, the patient is not getting that. Again, in a city centre where the transfer time might be five minutes, perhaps that does not matter as much as it does in a rural area, where once the ambulance has got to the patient, simple geography may mean that it takes 40 or 30 minutes to get back to the hospital.

In summary, we hear a lot about the problems that the ambulance service has. I agree with my hon. Friend the Member for Gainsborough (Sir Edward Leigh) that a Lincolnshire service would provide a better solution than one that covers such a wide geographical area as the east midlands, but I would be grateful if the Minister could look at the other potential solutions.

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I have three points to put to the Minister. No. 1—will the Minister commission a report into the locations that have disproportionate numbers of ambulance call-outs by East Midlands ambulance service? I have highlighted one previously—Sports Direct in Shirebrook, which was getting more than a hundred a year. What was going on there was that the workforce was not allowed to make GP or other appointments in work time and therefore were continuing at work, fearful of taking any time off when sick, until they required an ambulance to be called. That could have been solved in very simple ways, but EMAS did not investigate the fact that there was an extraordinary level of call-out there.

A more common example is a care home that does not have properly qualified nursing staff, and therefore over-uses ambulances. I suggest to the Minister that if there are more than, say, 20 call-outs to one location, EMAS ought to be required to go in to see exactly what the solution is. The solution is not to send ambulances there expensively if they ought to be elsewhere saving lives. It is a simple process. It is amazing that that was allowed to happen at Sports Direct. The stats were there, but there was no intervention.

No. 2 is privatisation. One of the problems with EMAS—

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Will the hon. Gentleman give way before he rushes from No. 1 to No. 2?

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I will.

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The hon. Gentleman is again making a compelling case. He is actually arguing that demand varies, and that we need to look at the character of demand, at how we respond to it, and at the drivers of demand. It is of course always about resources, but it is not just about resources. The hon. Gentleman is making that case in his typically sophisticated way.

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A very wily intervention by an experienced Member. I look forward to such a commission, which I think would be very helpful to the Government and residents of the east midlands.

The absurd privatisation of the non-emergency ambulance service in the east midlands—Arriva is responsible for it in Nottinghamshire—was cross-subsidised. The £5 million that it really cost EMAS came from, in essence, ambulances that were diverted. Put simply, if there was an emergency call, an ambulance ferrying somebody routinely to hospital would be diverted, and the patient waiting would wait an hour longer. That was a rational cross-subsidisation. The moment it was privatised —sadly in 2009 by a Mr Burnham, under EU procurement rules—there was a serious deterioration. It is obvious in an area that is rural, but not just, that an ambulance going from point A to point B that could be immediately diverted into being an emergency ambulance would increase the capacity significantly. Reversing that privatisation with the freedoms we are about to have once we have left the European Union would be a significant improvement for the NHS.

No. 3, most controversially, is geography. Why is the ambulance service based on the east midlands? I am not exactly sure where the east midlands is. The South Yorkshire ambulance service operational base is actually in the east midlands—it is across the border in Chesterfield. Senior managers were clear to me in private that for certain areas, including mine, given that ambulances go to hospitals in Bassetlaw, Chesterfield, South Yorkshire, Doncaster and Sheffield, which they do—all heart attack patients in my area go directly to Sheffield and all stroke patients go directly to Doncaster—rationally we should be part of the South Yorkshire ambulance service. It makes no sense to have this historical, arbitrary divide, given that in the practical, real NHS world any business would have reorganised it in that way. The fact that the major response centre for South Yorkshire is actually in the east midlands demonstrates that point vividly. We need a bit of common sense here.

We need a reversal of privatisation. As it was an absurd Labour-inspired proposal initially, it will be easier for the Minister to agree to that and to whack Mike Ashley and other misusers of the service. Rather than simply respond to the people who are wrongly using the service, they could be, if necessary, publicly embarrassed so they change their systems. I offer those three easy options to the Minister.

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It is a pleasure to serve under your chairmanship, Mr Davies. I pay tribute to the workers on the frontline of the East Midlands Ambulance Service NHS Trust. At a constituency event, I met one who had had two teeth knocked out by a patient he was trying to help. He said, literally, “It is all in a day’s work.” Those dedicated people are doing great work. I want everything I say after this to be taken in that context.

EMAS receives a call every 34 seconds. It has been keen to embrace innovations—for example, it has done work in Lincolnshire on sepsis—which complements some of the challenges we face at United Lincolnshire Hospitals NHS Trust. It is telling that six of the seven Lincolnshire Members of Parliament are here in this Chamber. Lincolnshire faces the greatest challenges, although I do not want to diminish the challenges that EMAS faces elsewhere.

Originally, we had a Lincolnshire ambulance service. As my hon. Friend the Member for Gainsborough (Sir Edward Leigh) has said, EMAS was created to fix some of the problems we had in Lincolnshire, but I suggest to the Minister that it has palpably not done that. Some of the problems relate to handover. Only yesterday, a constituent informed me that there were 10 ambulances queuing outside Pilgrim Hospital, and he has informed that at one point today there were 11. I make that point not to criticise a single member of the ambulance service but to endorse the point made by my hon. Friend the Member for Sleaford and North Hykeham (Dr Johnson). It is clear that we face problems, and we should look at how to solve them.

My right hon. Friend the Member for South Holland and The Deepings (Mr Hayes) made a fair point when he said that there are problems with the management at EMAS. To give but one example, I have raised problems with EMAS every time I have attended health debates in this place, and EMAS has not made a single proactive attempt to reach out to explain even what it is trying to do. I suggest that the waiting times and the service we get from management indicate that the ambulance service is not serving us, as the elected representatives of patients, or patients themselves. This is a serious situation.

I have a number of suggestions to put to the Minister. First, he should support the Lincolnshire County Council manifesto commitment to create, or at least to explore, a Lincolnshire ambulance service. In various parts of Lincolnshire—particularly in my coastal, sparsely populated constituency—there is a huge drain on resources as ambulances inevitably go westwards and do not come back. A Lincolnshire ambulance service, using sensible modern technology, could achieve a great deal more than what was possible under the previous regime, and would address some of the challenges we face simply due to the rather random creation of EMAS—as the hon. Member for Bassetlaw (John Mann) has said, the east midlands is an area that does not really exist in the mind of the public.

To go slightly further, it would be good to see the Minister continuing the work that was done prior to the reshuffle, looking at what we can do sensibly to combine blue-light services. We already do some creative work in Lincolnshire with the fire brigade. We do some really important, sensible things that allow the fire brigade to save lives. Indeed, in some cases, they are saving lives that, under previous, unreformed systems, would not have been saved. There is good work to build on.

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Does the hon. Gentleman agree that if we ask firefighters to extend their role, that should be properly resourced and funded and not just given as an extra job on top of what they do already?

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I agree, of course, that we need the resources and reform package that will put us where we need to be. As my right hon. Friend the Member for South Holland and The Deepings has said, the issue is not solely about money—though to be fair to everyone present, I do not think that anyone is pretending otherwise —but of course proper resources are a big part of the equation.

Sensible moves on a blue-light combination would be a logical thing to do. I also think that one of the problems we face—this relates both to the issue of handover and to the number of ambulances waiting outside hospitals—is in large part due to the recruitment and retention challenges we have in Lincolnshire. A medical school in Lincolnshire would play a part in solving some of those problems. I say that in part because we need to recognise that this is a system problem, not solely an EMAS problem.

In conclusion, I was all set before the debate to stand up and say that successive Governments have not managed to get a grip on this problem—

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Do I not get an extra minute?

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It was a five-minute limit and I did give you some 45 seconds’ discretion.

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I personally have witnessed how hard EMAS staff work. I pay tribute to their professionalism and dedication.

On 18 January my right hon. Friend the Member for Islington North (Jeremy Corbyn) came to Lincoln and we visited the call centre up at Bracebridge Heath. We saw at first hand what was happening. We were told that the single biggest problem in the increase in response times is when the ambulances get to hospital and cannot hand patients over. The day before I went out with an ambulance crew, there had been a seven-hour wait to hand over and at 7 am the next morning 22 patients were still waiting in A&E for a bed. As I have said, during my right hon. Friend’s visit we talked to ambulance crews and the handover time at hospital is causing the problem and increasing response times.

On 3 January I went out on my own with a crew—I, too, am a healthcare professional: a nurse. Ordinary people were phoning for ambulances. An elderly gentleman called one because he could not breathe and was terrified —he actually had a chest infection, so he was given a nebuliser and did not have to go to hospital, but he had not been able to get a GP appointment. We went to an old lady who had fallen and was on the floor. The paramedics dealt with her and within an hour we left her—she stayed at home and did not need to go to hospital. Our ambulance services deal with all sorts of cases.

A more personal example is my mum, who has mental health problems—she had a breakdown a few years ago, The Friday before Christmas, at half past 4 in the afternoon, I was called from my office to go to her. I went, called 111 and got her assessed by about 6.30 pm or 7 o’clock. I did not get an ambulance until quarter to 1 in the morning. She just had to wait. There was a bed at Witham Court, but we could not get an ambulance. My mum was getting increasingly distressed—she was in a right state and I had to sit with her. If I had not been there, my stepfather would have had to deal with her, and he has dementia. I was wandering around Tesco at 2 am on the Saturday before Christmas because I had had to stay in to look after my mum—another ambulance wait.

Other examples are personal to me because I am a cardiac nurse. When my right hon. Friend the Member for Islington North came to Lincoln, we went to the heart centre. I am also aware of stuff that has come through my post bag about people with chest pains waiting two and a half hours for an ambulance. The figures for issues such as door-to-balloon time are all going up at Lincoln County Hospital because people who are actually having heart attacks cannot get an ambulance. They are at risk of going into an arrhythmia, whether it be VT or VF—ventricular tachycardia or ventricular fibrillation—because they are having a heart attack. They are not getting the treatment they need, because they are waiting for an ambulance.

Our NHS is in crisis. It is time that the Government acknowledged that. If A&E is so packed that ambulances cannot hand over, the NHS is in crisis—please admit that and let us do something about it. What is happening with EMAS is symptomatic of the situation. NHS workers are underpaid right across the board, with a pay cap, and they are understaffed. All those things work together. I feel sorry for EMAS—at the moment it is set up to fail and there is nothing it can do about that. I am sorry, but this is utterly political: why do we starve public services of resources? It is all right to say that we are giving them money, but we are not giving them enough money. When we do not give them enough money but cut taxes, frankly that is immoral.

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I call Ben Bradley. Is he here? He has just walked out, has he? He was here. I am sorry about that. I will call the first Front Bencher instead.

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Thank you for calling me to speak, Mr Davies. Perhaps the hon. Member for Mansfield (Ben Bradley) had a call from his lawyers.

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He has called an ambulance, I should think.

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I congratulate my hon. Friend the Member for High Peak (Ruth George) on securing this debate. She has again shown that she is a strong advocate for issues in her constituency. She described the ambulance service as the glue that binds the NHS together; I would go further and say that all the staff are that glue who bind the service together.

My hon. Friend reeled off a whole range of statistics about performance in EMAS. The ones that stuck out for me were the nine-hour wait for an ambulance and the queuing times at hospitals, which were also mentioned by a number of other hon. Members. She talked about the risk-averse approach of 111; although clearly no one wants that to go too far the other way, I know that more clinicians are now working for 111. I will be interested to hear whether the Minister feels the balance between clinicians and non-clinical staff in that service is now right.

We heard from a number of Members, but unfortunately I will not have enough time to go through all the contributions. In a very thoughtful and relevant speech, the hon. Member for Sleaford and North Hykeham (Dr Johnson) made some interesting points about whether staff are utilised as effectively as we might like.

My hon. Friend the Member for Bassetlaw (John Mann) made some interesting points about geography—he should look at some of the sustainability and transformation plans too, to see whether the geography there makes any sense—and privatisation, which probably got a fairer hearing from Members on our side of the Chamber than those on the Government Benches, but that is something we need to examine closely.

We also heard from my hon. Friend the Member for Lincoln (Karen Lee), who spoke movingly and passionately from her personal and professional experience. We heard about people with chest pains waiting two and a half hours for an ambulance—we can only begin to imagine how stressful that must be.

As a number of hon. Members said, geography is clearly a big issue. As we also heard, the trust is one of the most poorly performing in the country. The sparsity of population is clearly driving that problem. The staff are not to blame. Last year the Care Quality Commission report expressed serious concerns but also commented on

“caring, professional staff delivering compassionate, patient focussed care in circumstances that were challenging due to the continued demand on the service.”

It is important to remember that across the whole of the NHS, providers struggle to meet the demands.

The financial squeeze has been pointed out on more than one occasion, not only in this debate but by many politicians, patients and staff, and by the assistant coroner for Nottinghamshire, Heidi Connor, in her comments in the regulation 28 reports to prevent future deaths, all of which have been sent to the Department of Health and Social Care, NHS England and NHS Improvement. As Members know, the reports are made when a coroner believes that action should and can be taken to prevent future deaths. In May 2016, in the second of two reports expressing concern, she said:

“The issue in this case…was essentially a matter of resource. In essence, I found that there is only so much an ambulance service can do where they simply do not have an ambulance to send. Demand is clearly greater than the resources they have most of the time”.

We have heard that echoed by Members.

We know that there will be occasions when demand peaks, but Heidi Connor makes it clear that that is not an exceptional spike in demand but a situation that exists most of the time. She goes on to say:

“I consider that there is a risk of future deaths...unless an urgent review of resources is undertaken”.

Will the Minister confirm what specific steps were taken by the Department in response to the regulation 28 reports issued on 11 and 26 May 2016?

Those statements are not the only ones we have heard about the resource situation. After the 2017 CQC report, the chief executive of the service said:

“EMAS was not commissioned to meet the national performance targets during 2016/17, and therefore was not resourced to do so”.

As my hon. Friend the Member for High Peak said, there can be no doubt that finance is the root cause of the issues we are hearing about today. We are in the longest and most sustained financial squeeze in the history of the NHS, and that is having real consequences. The fact that EMAS receives the second lowest urgent and emergency income per head of population in the country is a challenge, in particular given the sparsity of the population and the geographical challenges, as we have heard.

Despite the pressing need to invest more in frontline services, I am concerned that EMAS is having to service debts that have increased from £35,000 to £376,000 in the past year as a result of a loan taken out from the Department of Health in 2015-16. How can the service deliver the improvements we all want when it has to divert money to repay debts, just to keep things on the road?

It is true that EMAS’s performance is below average; it is also true that trusts have deteriorated significantly in their performance since 2010. The same is true of all targets in every part of the NHS. This Government have failed to hit any of their NHS ambulance targets since May 2015. The truth is that underfunding of the NHS has pushed ambulance services to the brink and left record numbers of patients everywhere suffering in discomfort and in terrifying circumstances, as we have heard today.

New performance standards are an opportunity to build a system that has the support of paramedics and patients alike. I conclude by asking the Minister to give an assurance that the new series of standards are based on the best clinical evidence and not just designed to obtain what is achievable with the money that the Department has allocated.

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Minister, we will end at a quarter to, so you will have time to allow a couple of interventions should you wish.

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It is a pleasure, as always, to serve under your chairmanship, Mr Davies. I am very keen to allow a little time for the hon. Member for High Peak (Ruth George) to speak at the end, should she wish to do so.

I begin by congratulating the hon. Lady on securing this debate and welcoming the opportunity to discuss the performance of the East Midlands ambulance service. My hon. Friend the Member for Boston and Skegness (Matt Warman) mentioned that six out of the seven Lincolnshire Members of Parliament were present; this issue generates considerable interest both among Members and the constituents that they serve. I assure the hon. Lady that we are taking her concerns seriously. We recognise that the trust’s performance needs to improve. A range of local and national actions are under way to support it in doing so, and I will set out more details about that.

Key measures include the implementation of a new urgent care transport service, to take pressure off emergency ambulance responses; action to address handover delays at hospitals across the east midlands area; and a demand and capacity review of the trust, to ensure that it has the right levels of resource.

Sitting suspended for Divisions in the House.

On resuming—

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Order. Minister, over to you; if you would like, you could allow a couple of minutes at the end for the mover.

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I will be happy to, Mr Davies. As I was setting out before the votes, a number of key measures have been announced. I will elaborate on those further, but, before I do, I will address some of the points raised by colleagues across the House in this constructive and well supported debate.

The hon. Member for High Peak very reasonably opened her remarks by putting some of the challenges in the context of the good work being done. She cited in particular the case of her constituents, Vinnie and Jo, which illustrates the fantastic work done alongside some of the challenges that we will come on to. She also mentioned specific issues faced in terms of geography and low population density.

The hon. Lady mentioned empowerment of 999 call staff as a specific issue. My understanding is that revalidation can be done by call handlers where they are clinically trained, but not where they are not. Even where they are clinically trained, it cannot be done if the initial 111 call is either a life-and-death call—a category 1 or category 2 call—or where the initial assessment has been done by someone from 111 who is clinically trained. There is a framework there, but I am happy to have a further conversation with the hon. Lady if she has areas of specific concern about how that guidance is operated. She will be aware that, in any event, only 12% of NHS 111 calls are referred to ambulance trusts, so the 12% is a subset initially; within that, there is a subset of those who are clinically assessed and what power there is. I am, however, very happy to have a further conversation.

The hon. Lady also mentioned funding, which I will come on to specifically. The trust has had additional funding, but on the challenges set out by colleagues from across the House, the trust is undertaking a demand and capacity review that will determine the level of additional resourcing required. That will inform the commissioning for 2018-19. Of course, it will have taken note of the concerns raised.

The hon. Member for Great Grimsby (Melanie Onn), who is no longer in her place, raised a point about whether there are peaks of demand linked to drug and alcohol-related calls. I am happy to pick that up as a specific action and investigate that further.

As so often when we debate matters of health, my hon. Friend the Member for Sleaford and North Hykeham (Dr Johnson) brought a much-valued practical experience to the debate. I was particularly struck with her comparison between the one-to-one staffing rate in intensive care and her concern about the number of crews, and how that interplays with the handover at hospital. As she will be aware, a lot of work is happening on hospital ambulance liaison officers and how hospitals deal with ambulances. NHS Improvement and NHS England are looking at that issue specifically in relation to this trust, but again she made a helpful contribution. I know she mentioned that she had spoken to the Secretary of State about the issue.

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I, my wife and our 17 and 13-year-olds have all been at A&E at Pilgrim Hospital, on two occasions by ambulance in an emergency, so I speak with that knowledge. The Minister will appreciate the problems in rural Lincolnshire; he knows it very well, as he represents a seat just on the border of my own. Will he apply the work he has just described specifically to Lincolnshire and ask for his officials to look at the circumstances in Lincolnshire? It might well apply to other rural places, by the way. We feel particular pressure, as he has acknowledged, and that kind of reappraisal would be welcome in the county.

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My right hon. Friend makes a pertinent point. As he mentioned, he is my constituency neighbour and I am very aware of the specific challenges posed by the geography and the road network in Lincolnshire. I am happy to take that specific point forward. It will not surprise him that I have already zeroed in on some of the challenges in Lincolnshire, particularly around United Lincolnshire and Northern Lincolnshire and Goole, how that interplays across the spectrum of primary care, how the patient pathway goes through, the various blockages in the system and how we look at that in a more systemic way.

That issue interplays with a much wider debate, outside the scope of this one, but to give my right hon. Friend one statistic, 43% of beds are occupied by 5% of patients. If we take the average length of stay from 40 to 35, that is the equivalent of 5,000 hospital beds, each at £100,000 per year. We can see how there is an interplay between what we are debating with the ambulance services and the wider Lincolnshire health economy, which is a specific point. I am happy to have further discussions with him on that.

The hon. Member for Bassetlaw (John Mann) raised three points about the report on the disproportionate calls, which were pertinent to a conversation I had just this morning about spikes in care homes and what action might be taken. For example, to what extent can we improve GP access into specific care homes in Lincolnshire through Skype, as one of the mitigations of ambulance demand? We are looking at how we assess the return on investment between the cost of ambulances and emergency admissions and what that investment might do if it were put into a more preventative role—care homes, for example.

On the specific matter of Sports Direct, which I was not aware of, the hon. Gentleman makes a valid point, which I will be keen to look at with officials—where there are peaks of demand, what is driving those peaks and how to mitigate them. He also mentioned the issue of privatisation from 2009. We are looking at how we take a more holistic view across a landscape and how mutual support from different parts of the system can provide assistance to that. It will not surprise the hon. Gentleman, knowing my views on Brexit, that for all the talk of some of the challenges of Brexit, the opportunities of Brexit should not be missed. I share his desire on that.

There is also the geography point—whether it is the way services elsewhere have been reconfigured or the extent to which there are, for example, centres of excellence to which his constituents are being taken. Is the issue the formal geography or how the operating protocols within that geography have evolved? That, again, is a perfectly valid point and one we can look at on a case-by-case basis.

I know my hon. Friend the Member for Boston and Skegness has championed a number of these issues over a period of time. He raised how we can get the ambulance service working together with the other emergency services. I know that is an issue that many police and crime commissioners have also identified, and many within the fire service are keen to ensure that we have a better join-up between the blue light services.

The hon. Member for Lincoln (Karen Lee) raised the issue of hospital handovers. I assure her that daily reviews are currently being undertaken by NHS England and NHS Improvement. Greater transparency and targeted assistance is being provided, and there are also specific initiatives linked to individual hospitals, particularly including the hospital-ambulance liaison officers.

The hon. Lady also mentioned pay. It is worth reminding the House that the pay band that applies to paramedic staff has been increased from band 5 to band 6, so there has been a recognition in the system of the importance of paramedics, alongside an increase—around 30% since 2010—in the number of paramedics. However, we recognise that there is also an increasing demand, and that this service has been under considerable pressure.

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The Minister has skirted around the issue of breaking up EMAS, which I think some areas might quite like. Does he agree that our priority should be having more paramedics and ambulances, not more chief executives and office buildings?

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I think most people who observed my questioning during my four years on the Public Accounts Committee will know that organograms and looking at where investment is and how streamlined structures are is extremely important to me.

At the same time, it is important that one does not make a false saving in driving down some of the management costs, so that procurement, IT investment and consultancy spend, for example—some of the big ticket expenditure—is not effectively managed and escalates. There is a balance to be struck between having good leadership of trusts and, as my hon. Friend alludes to, not drifting into areas where additional hires are created in the back office as opposed to services on the frontline, where I think Members from across the House want to see them.

In terms of the service nationally, a number of actions have been taken. Under Sir Bruce Keogh’s review of the NHS urgent and emergency care system, ambulance services are being transformed into mobile treatment centres, making much greater use of “hear and treat”, which is treating patients over the phone, and “see and treat”, which is treating and discharging patients on the scene. While we have heard of some of the challenges faced by the trust, it is also worth placing on the record that it is one of the best-performing trusts for “hear and treat”, and treats and discharges more than three in 10 patients either on the phone or on scene. There are areas of good practice that, for balance, it is only fair to recognise.

I will conclude, to allow the hon. Member for High Peak time to speak. We recognise that the trust has challenges, and I am very happy to work with the hon. Lady and other colleagues as we move forward to address those. In addition to the increase in pay bands and the increase in numbers, an active plan is under way to tackle some of the challenges we have heard about today, which I hope gives some comfort to the hon. Lady.

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I thank all Members who have spoken from both sides of the House for the constructive way in which they have approached the debate and some of the constructive proposals that have been put forward. To the Minister, I say I am keen to look at the 111 service and how we can reduce those 1.3 million calls that come from 111 into the 999 service. I think that would be viewed as very helpful across the service.

On the geographical issues that have been mentioned, my constituency is High Peak, which is very rural. Yes, we take ambulances out of area to urgent and specialist areas, but we also get back. Sometimes, in rural areas in particular, such as Lincolnshire, where, as the hon. Member for Boston and Skegness (Matt Warman) said, 10 or 11 ambulances can be backed up outside a hospital, it can help to organise support on a regional basis. However, I will not go to the line on that.

It all comes down to resources at the end of the day, as we have heard. EMAS has put in more and more paramedics and squeezed the managers—7% of the 8% of the management staff are on the frontline anyway and do frontline shifts. Not only are they managers, but they are also frontline staff, so the managers know exactly the challenges facing the service. I hope we would all agree that that is needed across the NHS.

The debate has shown the pressures on not only the ambulance service but GPs, A&E departments and the NHS as a whole, and I hope the Minister will take that up across the board.

Motion lapsed, and sitting adjourned without Question put (Standing Order No. 10(14)).