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Ambulance Pressures

Volume 823: debated on Tuesday 19 July 2022


The following Statement was made in the House of Commons on Monday 18 July.

“Following the announcement by the Met Office on Friday of a red warning for extreme heat, I would like to update the House on the impact of extreme weather on health and care, the current Covid infection situation and our plans for Covid and flu vaccines this autumn.

This is the first time in its history that the Met Office has issued a red warning for extreme heat. The warning covers today and tomorrow. In addition, the UK Health Security Agency has issued its highest heat alert. Its level 4 alert, issued to health and care bodies, means that the heat poses a danger to all of us, not just high-risk groups. Although for many the risk from this heat can be mitigated by simple, common-sense steps, the extreme temperature poses a particular risk in respect of cardiovascular conditions, including heart attacks and strokes. Level 4 does not change the contingency plans in place across the health system, only their likelihood.

We have taken a number of steps in response. COBRA has convened several times, including over the weekend and earlier today, to co-ordinate every part of the Government’s response to this emergency, and I have held a series of meetings with the chief executives of ambulance trusts to discuss the specific measures that they are taking. Steps include increasing the numbers of call handlers; extra capacity for ambulances; and extra support for fleets, including the buddy system, so that calls can be diverted to another trust if there are delays in the area people are calling from. We have held numerous meetings with NHS leaders, including the chief executive of the NHS and her senior team, to continue to implement their long-standing heatwave plans. We had a further meeting again this morning. Meanwhile, ministerial colleagues have continued to liaise with our local resilience forums to co-ordinate across both health and social care.

Even before this heatwave, ambulance services in England have been under significant pressure from increased demand, just as they have across the United Kingdom. The additional pressure on our healthcare system from Covid-19, especially on accident and emergency services, has increased the workload of ambulance trusts; increased the average length of hospital stays; and contributed to a record number of calls. Taken together, that has caused significant pressures, which are now being compounded by this extreme heat.

We are taking action on in a range of areas. In May, NHS England published a tender for auxiliary ambulances to provide national surge capacity to support ambulance responses during the period of increased pressure. Alongside measures in ambulance trusts to assist with call handling and capacity, NHS hospital trusts are taking steps to address handover delays, in the interests of patient safety. On Friday, the NHS medical director, Steve Powis, and the Chief Nursing Officer, Ruth May, wrote to the chief executives of NHS trusts, ambulance trusts and integrated care boards setting out some of the urgent interventions we need to make; most significantly the focus was on improved ambulance handovers and increased hospital bed capacity.

On ambulance handovers, we are asking health leaders to look again at the balance of risks across the system. We know that leaving vulnerable people in the community would have serious implications for patient safety. Equally, we know that keeping people in ambulances for too long carries other risks, especially from heat. NHS leaders are therefore asking hospital trusts to create additional space for new patients in their units. That may involve the creation of observation areas or exploring ways to add additional beds elsewhere in hospitals, including by adjusting staffing ratios where necessary, as we did during Covid, and working to identify areas to mitigate additional workload, such as through greater support on wards with pharmacy and administration.

The NHS is executing its urgent and emergency care recovery 10-point action plan, which includes action across urgent, primary and community care to better manage emergency care demand and capacity. The NHS medical director and chief nursing officer both recognise that this will place an additional burden on some staff, so they are asking trusts to increase efforts on staff wellbeing and support. Alongside the measures being taken by the ambulance services and NHS trusts, the UK Health Security Agency is leading on public health comms to reduce the burden on NHS staff by making sure that we do not create unnecessary demand. We can do that by following the common-sense public health guidance and by looking out for others, in particular the elderly and the vulnerable.

With services under so much pressure, we must make sure that 999 calls are reserved for life-threatening emergencies. We must also consider what advice we can get through other services such as NHS 111, NHS online resources and local pharmacists. In addition to the immediate steps to mitigate the pressures on 999 calls, ambulance services and adult social care, we will keep building on our operational response, with particular attention to discharge and expanding on our pockets of best practice.

That is particularly pertinent, given the current levels of Covid, which continue to rise. The latest data from the Office for National Statistics shows that the percentage of people testing positive for Covid continued to increase across the UK. In England, an estimated one in 19 people tested positive in the week to 6 July, compared with an estimated one in 25 during the previous week, with more than 13,000 patients admitted to hospitals with Covid-19.

Given those pressures and the expected pressures this autumn and winter from respiratory viruses, we are taking important steps to further align our offers on Covid and flu. On Friday, I accepted the Joint Committee on Vaccination and Immunisation’s recommendations for a Covid-19 autumn booster programme, focusing on vulnerable cohorts, including everyone aged over 50. At the same time, I took the decision that we should keep offering flu jabs to more cohorts than we did before the pandemic. Taken together, this will reduce the number of people getting seriously ill this autumn and winter, easing pressure on the NHS at a critical time. Vaccines have always been, and continue to be, one of the best protections we have, both for ourselves and for the NHS.

From this heatwave to the foreseeable pressures in autumn and winter, I will continue to work closely with colleagues across health and social care, as well as with Members across the House, to ensure that we can address the challenges ahead. I commend this Statement to the House.”

My Lords, the Statement suggests that everything is in hand. This was not the case before the heatwave, and it is not the case now. Just last week, in response to an Urgent Question, the Minister said,

“we fully acknowledge the rising pressures facing the service”. —[Official Report, 13/7/22; col. 1489.]

She spoke of some of the contributing factors: near maximum bed occupancy, high rates of Covid admissions in hospital, pressure on the ability of A&Es to admit patients, an increase in the length of stays, delayed discharges and record numbers of calls to the ambulance service. I am glad that the Secretary of State also referred to these pressures. However, does the Minister acknowledge that the Government have allowed these unsustainable pressures to develop? If not, can she indicate where the responsibility lies?

To that list I would add the failure to provide a wraparound, long-term plan for social care, and insufficient planning and attention to the recruitment, retention and training of health and care staff. Can the Minister say what action will be taken to address these shortfalls, as well as the other pressures on the system, which Ministers themselves have acknowledged? All these pressures, along with a record 6.6 million people waiting for NHS treatment, often in pain and discomfort, were in place long before the pressure of an unprecedented heatwave.

The Statement talks of creating additional space for new patients in hospitals. Will this be in existing hospitals? How and when will that happen? What money, resources and staff will be allocated? What does additional space actually mean? Can the Minister give an assurance that this will not mean more patients being left in corridors on trolleys or in car parks?

The people about whom we speak today are those waiting in queues of ambulances outside hospitals, in soaring temperatures, unable to enter the very place that they need to be, while people with conditions triggered by excessive heat are struggling to get an ambulance in a timely fashion because ambulances are log-jammed outside A&E. What can the Minister offer to them and their families?

The situation is impacting mental health too. People attending A&E experiencing a mental health crisis may not be able to get a bed in a psychiatric hospital, and their wait in A&E can be more than three days. What assessment has been made of the impact of cutting a quarter of all mental health beds?

Last week, the Minister of State in the other place said that the Government had procured a £30 million contract for an auxiliary ambulance service, but in fact it was yet to be awarded. Can the Minister confirm whether a correction has been issued to this statement?

I wonder if it is possible to comment on why the Prime Minister did not chair COBRA yesterday, despite the country being in the midst of a national emergency and ambulances finding themselves on the highest level of alert.

On practicalities, has there been any discussion involving the military to seek its assistance at any time? What is being done to reduce injuries and discomfort for ambulance crews who need to have the right vehicles in place for them to use but find that they do not?

It has been 10 months since the Government closed their national resilience strategy consultation. Can the Minister tell your Lordships’ House when we can expect the Government to publish their response?

I am sure we are all agreed that credit and thanks are due to all of the staff team, but if they are overworked in health and social care and do not have the time and resources to take care of themselves in this heat, the care that they give patients will be affected. Heatwave working poses new challenges for paramedics and all health and care staff, who may be wearing thicker PPE. Can the Minister outline any discussions the department has had about ensuring safe and comfortable working conditions?

In the midst of this unprecedented heatwave, can your Lordships’ House be reassured that, when it comes to the pressure that winter presents, steps will have been taken to ensure no further crisis in the ambulance service and across the health and care sector?

I hope the Minister will acknowledge the need to build resilience and for us all to see urgent action.

My Lords, I start by paying tribute to our ambulance and paramedic staff, as well as the ambulance call handlers. They are doing the absolute best they can despite the circumstances, and we owe them an enormous debt of gratitude.

There is no doubt that our ambulance services are at breaking point. Record-long ambulance waits are leaving vulnerable patients stuck in the heat outside hospitals, waiting for the treatment they need. There was a new first over the weekend, as temperatures rose, when patients inside ambulances were in a hospital car park for over 24 hours because A&E was full and there were no beds in the hospital.

This is not a recent crisis. Among many incidents reported in the press, a couple of months ago a senior NHS trust doctor in Gloucestershire rang 999 having had a suspected stroke, and was told to get a family member to drive her to hospital because no ambulance could get to her for at least an hour and there would then be a considerable delay after that. There are daily reports of people dying waiting for ambulances or in the back of an ambulance outside A&E.

Frankly, this Government have run ambulance services into the ground, with every single target being missed for the most severe cases. For months, they have failed to act on warnings that ambulance services are struggling to maintain a safe and timely service. The Government need to get a grip of this emergency. Even Liz Truss, one of the contenders to be the next Prime Minister and a very senior member of Cabinet, said in the ITV leaders’ debate on Sunday that ambulance waiting times in her rural constituency were “appalling”. Surely now is the time for Ministers to finally commit to commissioning the CQC to conduct an investigation into the causes and impacts of ambulance service delays, which would not just look at the very front line but take a whole, systemic approach.

One of the solutions proposed by the Secretary of State in the Statement is more use of 111 to ease pressure on call handlers receiving 999 calls, but there is already a major problem with 111: it takes much longer to get through and sometimes calls are not even answered. Not getting through to 111 will exacerbate waiting times and not help get them under control, because it risks piling even more pressure on our ambulance services, as desperate people whose conditions have worsened struggle and then turn to 999 instead. Can the Minister say what extra staffing and training there will be for the 111 service? Specialist training will be needed, because staff do not receive the highly specialised training that the 999 service call handlers do.

We need to remember that this is not just about ambulances, but they are the very visible evidence of a broken health and social care system. We on these Benches, and others around your Lordships’ House, have regularly been asking questions about our ambulance and A&E services, under pressure for well over the last six months. For years, we have also highlighted the shortage of hospital beds compared with other OECD countries. In 2021, the UK had 2.3 beds per 1,000 people, compared with France at 5.7 and Germany at 12.6. It was a mistake to cut so many beds. So will the Government undertake to fund thousands of extra beds to stop handover delays at A&Es, so that ambulances can get back on the road as soon as possible?

All of this is compounded by the lack of training and education places for doctors, nurses and other vital healthcare professionals, such as physios, occupational therapists, and speech and language therapists. Will any of the long-term plans to provide finance and support to enable hospitals to recruit and train more specialist healthcare staff be brought forward? Otherwise, we will just continue to lurch from crisis to crisis.

Finally, as the Statement notes, the Met Office has issued the first ever red warning for extreme heat, at a time when all 10 of our ambulance services in mainland England are already at the highest level of alert. The news this afternoon is of a number of serious fires in London and elsewhere; Hertfordshire, my local area, has had 240 calls to its fire service, which is many more than usual. Temperatures peaking at over 40 degrees centigrade just demonstrates that the pressure on ambulances, A&E and our wider NHS is likely to increase from injuries sustained by firefighters and those caught up in the fires.

The Statement talks as if the only effect is on people currently in hospital. The effects of climate change will make heat waves more frequent and intense in the future, so I ask the Minister what the Government are building in to help the NHS tackle the problems arising from these heat incidents, which sadly we must now plan for on a regular basis.

My Lords, I thank both the noble Baronesses for their questions. I will do my best to address them. The noble Baroness, Lady Merron, first asked how these pressures had developed. It is fair to say that, while not all ambulance trusts were meeting their targets before the pandemic, there has been a significant shift in performance since the pandemic. The levels of service we are seeing at the moment are tied to that event, but I acknowledge pre-existing pressures in the system. There was a real change due to Covid, which has affected a number of factors, including staff absence, infection control and pent-up demand, where people might not have accessed health services during the peak of the pandemic.

The noble Baroness, Lady Merron, talked about the lack of a social care plan. The Government have been working to address social care over a number of years, putting in additional resources and measures to spread best practice and to increase the recruitment and retention of staff. There is more to do, and we are doing it. In 2022-23 the local government finance settlement made an additional £3.7 billion available to councils. Local authorities can make use of more than £1 billion of additional resources specifically for adult social care this year. That is part of £5.4 billion over the next three years to end increasing care costs and support the workforce. Specifically, £0.5 billion of that is to support and develop the workforce.

The noble Baroness asked me about the recruitment and retention of staff. Just to touch on two areas in terms of staff, we know that some of the delays are due to delayed discharge and its impact on social care, so we are making efforts to recruit more social care staff. Care workers are eligible for the health and care visa; they have been added to the shortage occupation list. There has been a national recruitment campaign in this area, and we are working with DWP to promote adult social care careers. We have also put in resources to increase the number of certifications that people can get if they want to train in this area.

To touch on another area of staffing, the paramedic workforce, the number of ambulance staff and support staff has increased by almost 40% since February 2010. The number of paramedic-qualified staff has grown year on year. Health Education England has mandated a target of training 3,000 paramedic graduates nationally per year between 2021 and 2024, further increasing our workforce.

The noble Baroness, Lady Brinton, also asked about the workforce. Of course we have our targets to increase the number of nurses and doctors in the NHS and the number of domestic training places for both those occupations, and we continue to make good progress on both those areas. We need additional staff in our NHS, and efforts are being made to train them.

The noble Baroness, Lady Merron, and the noble Baroness, Lady Brinton, I think, asked about the letter that went out about measures to reduce the handover times with ambulances. My understanding is that that will not involve new pieces of hospital estate but rather making better use of the existing hospital estate. I assure them that that is looking not at more corridor care but at how the estate is used more flexibly.

The noble Baroness asked what reassurance I could give to families waiting for ambulances or those in ambulances waiting to be transferred to emergency departments. That was the aim of the letter that has gone out from NHS England. We are looking at the balance of risks. We now need to reduce handover times and wait times in the community because, when people have been through the urgent care process, there is a lower risk of having to manage increased demand through additional flexibilities at that stage, rather than people waiting in the community not having been assessed by a paramedic, for example. That is the aim of what was in the Statement yesterday.

As the Secretary of State made clear yesterday in the House, a contract is being procured for auxiliary ambulance services. That is expected to be concluded shortly. The noble Baroness also asked about the process around the COBRA meetings we have held. It is the Chancellor of the Duchy of Lancaster’s responsibility to chair the civil contingencies COBRA meetings, and that is what he has been doing. There were several meetings over the weekend, I think, and one yesterday. It will continue to meet as long as that is needed. I am afraid I do not have a response to her on the national resilience strategy consultation, so I will happily write.

The noble Baroness, Lady Merron, also talked about the support for staff working in the heatwave. That is absolutely part of NHS trusts’ plans for this kind of scenario. It was also re-emphasised in the letter from NHS England and NHS Improvement to trusts yesterday. She is absolutely right that we need to take steps now to build more resilience in the system ahead of the winter, when we know pressures grow. That is absolutely a focus for the Department of Health and Social Care, NHS England and NHS Improvement and others.

The noble Baroness, Lady Brinton, asked about resources going into 111. We are further building the capacity of NHS 111. We are increasing staffing throughout this year, scaling up call handling across regional footprints while maintaining a focus on getting patients access to local services. Additional funding was also put into this—£50 million in 2022-23—to support increased call-taking ability. I think I have addressed her points on training places. In terms of extra beds, to stop the A&E delays we have talked about, we are looking to make efforts to reduce the handover time to 30 minutes. I know that in other actions on delayed discharge, initiatives have been made such as step-down beds to try to increase the flow of patients through A&E.

Finally, the noble Baroness, Lady Brinton, mentioned the fires, which are of course extremely concerning. The London Ambulance Service is currently supporting the London Fire Brigade in responding to several fire incidents across London. They are in attendance, on scene, at a number of locations. The DHSC and NHS England are monitoring the situation closely. That is quite a live situation, so that is the best update I can give at this time.

My Lords, my noble friend will know that today the Government published the better care fund framework 2022-23, with some £7 billion to join up health and social care. Against a background of the problems that have been raised so far, particularly with delayed discharge, should not a bigger slice of that £7 billion go to increasing the capacity of places where people can be discharged to from hospital to complete their convalescence—to be assessed prior to going on, either back home or to a nursing home or residential care? We need more of those intermediate places to remove some of the blockages that have been referred to.

My noble friend will have heard me refer to step-down beds or places in my previous answer. He is right that the better care fund framework has been in place for a number of years to improve delayed discharge and the link-up between health care and social care. I am sure the framework document published today was based on the lessons of the operation of that fund in previous years and will seek to use that best practice going forward.

My Lords, does the Minister agree that the hot weather will get colder, but this dilemma of patients waiting for or in ambulances will not until there are more beds in hospitals, better care in the community and enough trained staff? What are the Government going to do to solve this problem, and will it include more vaccines for coronavirus variants?

The noble Baroness is absolutely right. Regarding the weather that we are experiencing at the moment, the latest operational feedback is that we have started to see some increases in demand in A&E and 999 calls with of heat-related illnesses, but the system is managing and is able to deal with them. But those pressures existed before the weather that we have had today; she is absolutely right. She also mentioned vaccines. As part of the Statement yesterday, my right honourable friend the Health Secretary confirmed that we will have Covid booster vaccines for all over-50s this winter, and we will continue the extended eligibility for the flu vaccine that we had in place last year to provide further protection this winter.

My Lords, all the things that the Minister has said, and that noble Lords have raised, are worthwhile and valid, but they will not address the problem that we have at the moment: paramedics are wasting their time in hospital corridors. Even more ironically, when their shift is over, another taxi comes along and gets the next lot to wait for them. In the meantime, as somebody has already said, it does not matter whether you ring 999 or 111 when you have suffered a stroke—you are going to die. That is according to figures that have been released recently; it is something like 40,000. It is appalling. The Government must do something immediately.

I drew this to the attention of the noble Lord the Minister when I gave him the example of a system in Wolverhampton. But for now we need to put in somebody with an iPad who will send the paramedics back out again. All the patient notes are there. We need something immediately. It is no good talking about what the Government are doing in terms of recruitment and extra beds; that is all great, but they are longer-term things. This has been raised not once but at least half a dozen times in this House. I cannot believe that anywhere else in the western world the Government just say, “Well, it’s difficult. We’re doing something: we’re going to try to provide extra beds”, yet still—

Yes, I certainly am. What steps are the Government taking to remedy the situation and get the paramedics back out there?

The noble Lord might not have seen the Statement given by my right honourable friend the Secretary of State for Health yesterday. A large portion of it focused on exactly the point that the noble Lord made. We need to do long-term things to relieve these pressures, but also more immediate things: specifically, to reduce handover times to no more than 30 minutes so that ambulances are not queuing any more and can get back on the road, so that people who have called an ambulance are seen faster. That means changing the assessment of the balance of risk to ensure that hospitals look at different ways of managing demand once people have been through the emergency care process. That may mean finding extra space within their estate or looking at how they manage their staffing to address exactly the point that the noble Lord made about the delay in handover times for ambulances needing to be addressed in the very short term while we also put in place all the other points. I know that he gave the example of Wolverhampton the other week to my noble friend, who I know took it away and relayed it back to the department to follow up on.

My Lords, further to the question asked by the noble Baroness, Lady Merron, we have heard some really quite shocking stories of mental health patients ringing ambulances every week or so. They are not facing emergencies; they have not had accidents. Surely it is imperative that such patients, who have an ongoing condition, are looked at away from A&E. Can my noble friend be very diligent and kind and answer the opposition spokesman’s question, and maybe say a bit more about this acute problem?

My noble friend is right that I did not address that point earlier, and I apologise for that. We are putting more funding into specialist mental health services to address some of the points that both the noble Baroness and my noble friend have made. On the number of psychiatric beds available, I will have to write to my noble friend.

I want to ask the Minister about an issue that was raised in the Health Secretary’s response at Questions yesterday. He mentioned a sprint review of delayed discharges, which have been referred to a number of times today. He suggested that it started on 1 July. Who precisely is doing the review, to whom is it reporting and will it be made public?

I think the noble Lord is referring to the national hospital discharge taskforce, which is running a national 100-day discharge challenge, which I think will be the sprint review. It is working across the health and social care system to address all the different pinch points. One of the associated aspects is that integrated care systems can now become discharge front-runners to share good practice and ambitious ideas, so that those who are doing best in this area can share best practice quickly with those who might need more support.

My Lords, I note that the Statement records that an estimated one in 19 people tested positive for Covid-19 in the week up to 6 July, compared with one in 25 the previous week. I am sure the Minister is aware that this week there has been a joint leading article from the editors of both the British Medical Journal and the Health Service Journal, entitled “The NHS is not living with covid, it’s dying from it”. The article suggests that the Government are “gaslighting the public” about the threat of Covid, and says that

“the epidemic is far from over”.

I should perhaps declare an interest here as someone who is in week seven of a Covid infection and still suffering symptoms.

The article suggests four measures that the Government should be carefully considering: masks on public transport and in health service settings, the return of free testing, working-from-home recommendations and gathering limits. Can the Minister assure me that the Government are at least giving consideration to that recommendation from such a serious source?

The Government keep our response to Covid under review and take advice from many sources, but there is also a huge breadth and depth of expertise within government. The noble Baroness is right that very high rates of Covid are currently circulating. We take matters such as long Covid very seriously, and we have put additional resources into making sure that there is support for people who suffer from it.

However, we are in a different position from when we had to have significant restrictions on people’s lives—the vaccine has been very effective in that regard —so the Government’s focus is on learning to live with Covid. The noble Baroness is right that it has not gone away, so we need to make sure that in our response we are well adapted to ensuring that we can continue to deliver good healthcare services while Covid is in circulation in the population.