East of England Ambulance Service NHS Trust
I want to start by making it clear that I recognise absolutely that there is intolerable pressure generally across the emergency care system, and there are serious issues that have to be addressed particularly around handover delays, and I include within that the sense that there is quite a variation from one hospital to another and we need to understand why it appears as though some hospitals are more successful than others in addressing this.
I also want to make it clear that it is not my intention to focus on the adequacy of funding of the NHS in this debate; that is for another occasion. The question I want to address here is whether the East of England Ambulance Service NHS Trust is doing all it can with the resources it has.
I also want to place on record my understanding that we have incredibly committed clinical staff in this trust, and I want to express my gratitude to them; they are often working under intense strain, frequently dealing with extraordinarily distressing and sensitive personal situations, and they do so admirably. I should also express my gratitude to the Minister for meeting me this morning to hear more about my concerns, and for the seriousness with which he listened to them.
My reason for calling this debate is that I met a senior employee of the trust, who is a whistleblower in effect, and who came to me with deep concerns about what is going on in his service. I found the testimony to be very credible and I took the concerns extremely seriously. I have seen a list of 40 cases of potential patient harm associated with delays in response times, including 19 cases where patients lost their lives.
Simon and Michelle came to see me about this very issue. Their 999 call was downgraded, and as an unintended consequence, they lost their baby girl, Darcey, in what appears to be one of a catalogue of failures in the interaction between the ambulance trust in the hospital.
I am grateful for that intervention, and the hon. Lady is doing exactly the right thing in pursuing that matter on behalf of her constituents. They deserve answers to the concerns that they have expressed over that tragic case.
Beyond the list of 40 cases, I understand that a further 120 incidents of potential patient harm and a potential 81 patient deaths have been associated with delays over this period of time. One case, which is not on the list of 40 that I have seen, concerns a constituent who does not want her family’s name to be mentioned. She has written to me as follows:
“My Mum had been ill from Boxing Day and finally on New Year’s Day she deteriorated to such a level that I had to call an ambulance. When I first logged the call they advised me that as she was still breathing we would have to wait an hour before a team could get to us. Mum’s health deteriorated further to a point that I had to place another call to the ambulance call centre as she had suffered a stroke and then a heart attack and had stopped breathing. My sister and I had to perform CPR whilst waiting for the crew. When they finally arrived, although they tried, they said that there was nothing they could do and she was pronounced dead.”
I should say that my constituent commends the crews that attended for the work that they did.
I have great respect for the right hon. Gentleman for bringing this debate to the House today. Does he agree that this is due to a systemic crisis, rather than to individual failings? Since publicising this issue in the Chamber some weeks ago, I have been inundated by cases of people from across the country, not just the east of England, who have experienced similar failings in the ambulance service. We must make it clear that this is not just about blaming managers at the East of England Ambulance Service NHS Trust; it is also about accepting that the Chancellor of the Exchequer and the Secretary of State for Health bear responsibility for what is happening to ambulance services across the country.
I thank the hon. Gentleman for his intervention. Ultimately, the Government are responsible for keeping the people of this country safe, with emergency services that work effectively. That is ultimately what we are debating.
This is not something that just happened over the Christmas and new year period. Just last Friday, the 91-year-old mother-in-law of some close friends of ours in south Norfolk fell on to a cold stone floor. They called 999 at 8:45 pm, but the ambulance did not arrive until 4 am. It left at 4.45 to go to the hospital, but she had to wait in the ambulance until 6 am. She then had to wait on a trolley for two more hours. That is intolerable; she is 91 years old. This could happen to a family member of any of us; we all have a stake in this. We have to recognise that it is intolerable. Another constituent has told me about his 92-year-old mother who broke her leg. She had a nine-hour wait, during which she developed hypothermia. Then a car arrived, rather than an ambulance, and she had to wait another 40 minutes for the ambulance. That is simply intolerable.
I am told that, according to the assessment of many people internally, the service over that period was unsafe, and that no assurances have been given that the trust would be able to provide a safe service in the future, if there were to be a period of very cold weather or a flu epidemic, for example. That is a matter of serious concern to the people of the east of England. On several occasions during the period, there were more than 200 999 calls that could not be responded to at the moment they came in, because no crews or ambulances were available.
The Care Quality Commission told me this morning:
“This is a service that is in crisis”.
It also said:
“Patients are at risk”.
However, the CQC appears to have confidence in the leadership of the trust. I fear that it is being complacent in its attitude, and that it is not taking seriously enough the number of patient harm incidents that I have referred to. I have deep concerns about whether any family member of mine, any constituent, or anyone else across the east of England who has to rely on the service will get a service that will protect and safeguard them in their hour of need. I am told response times in North Norfolk are dire—not just that the trust is not meeting the target but that the long tail beyond the target is deeply concerning. I do not have the assurance that we need.
The concerns appear to have been recognised because a risk summit was convened. According to the official guidance, a risk summit is normally triggered
“if there are significant and serious concerns that there are, or could be, quality failings in a provider or system.”
The guidance further states that a risk summit should be called
“only as a last resort”.
Well, we clearly have a last resort here.
My central plea to the Minister is that we need an independent governance review, and I would like a specific response to that because I genuinely believe it is needed, but I would like to raise the following specific concerns. I understand there was a £2.8 million underspend in the trust in month nine of the financial year. How can that be justified? Is the Minister satisfied with that?
I am told that more than 100 staff have been recruited but are currently on a waiting list to start. Some have been on the list for more than a year. I am told there has been no recruitment in Norfolk, which is where response times are at their worst. Staff have left without being replaced.
There was an independent assessment in August 2016, never published, by Operational Research in Health, which said that hundreds more staff are needed across the region to run a safe service. Why has that never been implemented? The only area where there has been recruitment of late, according to adverts online, is in Bedfordshire and Hertfordshire, the best-performing areas. The impression I am left with is that it is all about hitting the national target, rather than ensuring that all parts of the region are safe.
Interestingly, the online job advert has just been changed to include other counties, but the public board papers say there are no vacancies in those other counties. At the same time, lots of additional management posts have been created. There is a new deputy director of human resources, an associate director of HR, a deputy director of strategy and sustainability and other deputy director posts.
The trust has also doubled its spend on lease cars, which in November 2017 was up from just under £500,000 to nearly £1 million, with directors and deputy directors making no contribution. I am told that directors and deputy directors drive around in Jaguars, Range Rovers, Mercedes and Audi A5s. Is the Minister comfortable with that? The policy allows discretion by the director but, with a service that is under such strain, for me it is a question of judgment and culture in this organisation.
I am told there was a very late sign-off of the plan for the Christmas and new year period following the letter from Professor Keith Willett, so the trust was not better prepared than ever, which is the Government’s mantra. Did meetings take place between the trust’s chief executive and the chief executives of hospitals where the delays were at their worst in the run-up to the Christmas and new year period? We have a right to know.
The trust issued a statement that it had not been made aware of any patient safety issues internally, but that is not true. I have a copy of an email from a constituent to the chair of the trust on 9 January specifically referring to the fact that someone in the trust had come forward to raise patient safety concerns. Is that acceptable? It is a wholly misleading statement to the public. Does the Minister feel comfortable with that?
Is it acceptable that neither the chief executive nor the chair of the trust has been prepared to be interviewed publicly since the new year? When there have been so many patient safety incidents, surely they should be being held to account for that service on television and radio.
There has been a big issue about director presence over Christmas and new year, with claims and counter-claims having been made, and we need to get to the bottom of it. Will the Minister ensure that we are told who was actually on duty all the way through the Christmas and new year period? By that, I mean on duty and in the region—not at home in some foreign country—leading the service in this region. It was new year’s eve before REAP 4— Resource Escalation Action Plan 4—was declared. That is the highest level. Many people in the organisation felt it should have been happened before that, so that mutual assistance could have been secured from surrounding trusts. Why did that not happen?
A report was commissioned last year from SSG Health—a “phase 2 report”—on how the trust can save money. It has never been published. I have tried to get hold of it under freedom of information but my request has been refused. Will the Minister ensure that it is now put into the public domain? Given the scale of the crisis, which the Care Quality Commission has acknowledged, we have a right to know what that report says and what is being done about it. It cost more than £500,000 for this report on how to save money. That shows the scale of the culture problems that we face.
On late finishes, staff regularly work 14-hour to 15-hour shifts, but no data has been available from the trust to the staff side since February last year. In September, the trust removed the staff support desk, which was there to provide support to staff who were working very long shifts. No data has been made available by the trust to the staff side on “tail breaches”—these very long delays in getting to patients. The trust claims an exemption under FOI. That is symptomatic of a trust that fails to be open with staff representatives and with the public it is supposed to be serving. A constituent of mine who has worked for the trust has been declared “vexatious” for making FOI requests about patient safety issues, for goodness’ sake. How about that for the culture of this organisation! The matter is now with the Information Commissioner.
I believe, and I think the Government believe, that trusts should be entirely open; there should be an open culture, encouraging staff to speak out about patient safety issues. Will the Minister send a clear message to end the embargo on FOI requests, so that we can find out what is going on in this trust, rather than have it being kept from the public gaze? This is an issue of the utmost concern to the people of the east of England. People in this region need reassurance that they will be cared for and that the response will be there when they need it. It is frightening for anyone, but particularly for older people, to wait interminably for an ambulance to arrive when a loved one is very ill and potentially dying. This is intolerable in a civilised society and ultimately it is the Government’s responsibility to ensure that there is a service there to serve the people of this country.
First, I wish to thank the right hon. Member for North Norfolk (Norman Lamb) for securing this debate. I recognise the concerns raised about the East of England Ambulance Service, including questions about whether delays to ambulance responses have caused additional harm to patients over the Christmas period, and his concerns about the leadership of the trust and the role of the CQC. I assure him that I am taking these allegations seriously, both as a Minister and, as he knows, as a constituency Member of Parliament in the East of England. I have put in place a number of actions to immediately ensure improvements to services are put in place by the trust.
As the right hon. Gentleman will be aware, a risk summit was held this week, on Tuesday 30 January, which examined whether the service is operating effectively now and sought to put in place any required actions to improve it going forward. I have spoken personally to the chief executives of NHS England and NHS Improvement, and to the chair of the risk summit. I will expand on the findings further, but I wish to emphasise that a wide-ranging plan of immediate actions has been put in place to address the issues that were identified. Details of the action plan have been published today and a progress meeting in two weeks will be led by NHS Improvement and NHS England. I agree with the right hon. Gentleman about the accessibility of the trust leadership in respect of the chief executive and the chair making themselves available for media bids. I have communicated that to the trust.
I recognise that the right hon. Gentleman is concerned about the overall approach of the trust’s senior management and about the level of external assurance from the CQC. In addition to the action plan identified at the risk summit, which was attended by other external parties including NHS England and NHS Improvement, I have gone further by asking NHS Improvement’s executive medical director, Kathy McLean, to provide her own assurance to Ministers in the coming week. That will assess the immediate steps taken to address the concerns expressed in the House and whether actions suggested in the earlier external reports have been implemented. Alongside that, I am happy to have further discussions with the right hon. Gentleman about his specific point about the Association of Ambulance Chief Executives.
I am assured that, where there were serious delays in response times, the trust has identified all potential causes. Following an initial investigation, it is examining 22 such cases through the serious incident procedure. That will ensure that individual cases are properly investigated. The hon. Member for Peterborough (Fiona Onasanya) mentioned a specific case and we are determined to ensure that that is addressed. I am happy to discuss that with her further.
In terms of the report mentioned by the right hon. Member for North Norfolk, which was previously commissioned for the trust, I am happy to update the House and say that the report should be published as soon as possible. Again, that is an issue I will follow up.
Let me turn to the specific actions arising from the risk summit. I am advised that actions to deliver immediate service improvements are being taken forward under the following themes: ensuring that the trust has sufficient capacity for the rest of winter; the effective implementation of handover delay policy with hospitals; the proper execution of REAP level measures; staff access to executive leadership; sound escalation procedures; bringing in independent assurance around the serious incident investigation procedures; working with CCGs and other stakeholders to manage demand for ambulance services; and the full exploitation of emergency service collaboration with police and fire. As a result of those actions, to help to manage winter demand the trust will put eight additional vehicles on the road each day until Easter, with immediate effect.
Improvements will also be made to the trust’s adherence to the national REAP guidelines, and actions will be taken to moderate service pressures, which will allow the trust to de-escalate to REAP level 2. The trust is also working with hospitals to ensure adherence to the national guidance on handover delays, particularly where ambulances waiting to hand patients over receive a new 999 call, which was a specific point that the right hon. Gentleman raised. I also assure him that we will work closely to monitor the outcomes of the work to ensure that safe, high-quality ambulance services continue to be provided to his constituents.
The right hon. Gentleman has also raised concerns that the trust has underspent on its funding while putting in place a hiring freeze. The trust has worked to grow its frontline workforce, fielding 700 more staff since 2014-15, and has achieved a low rate of staff turnover. However, like the right hon. Gentleman, I want further assurance that the trust’s staff plans are sufficient to meet the demands facing the city. I will raise that in my discussions with NHS Improvement.
Substantial local initiatives are under way to improve the trust’s performance. Importantly, more money is being invested in the service: its funding was increased by £90 million this year—an increase of 10%—and it will further increase by £27 million over the next two years. Other significant actions include the deployment of hospital ambulance liaison officers in emergency departments to help reduce the incidence of handover delays, and an independent review of the trust to ensure that it has the appropriate resources and processes to deliver against its performance standards. I will expand on these measures further, but it is worth considering them in the context of wider national initiatives to improve ambulance performance more generally.
As I stated in the House on 22 January, the NHS is busier than ever and the ambulance service is experiencing unprecedented demand, dealing with more than 11 million calls every year. There were almost 7 million face-to-face responses from the ambulance service in 2016-17, which is a 14% increase over the past five years. Under Sir Bruce Keogh’s review of the NHS urgent and emergency care system, ambulance services are being transferred 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. In December, the East of England Ambulance Service NHS Trust resolved three out of 10 incidents on the scene without transporting a patient to A&E, freeing up resources to respond quickly to the patients with the most urgent needs.
Additionally, in July last year the Secretary of State approved a revision of operational and performance standards for ambulances following the ambulance response programme. These improvements have now been rolled out to all mainland ambulance trusts in England. The evidence behind this new framework is extensive, covering data collected from more than 14 million emergency 999 calls. The evaluation considered a number of key issues for the east of England, including prioritising responses to the sickest patients while helping to reduce long waits for ambulance responses, and ensuring that patients receive the most appropriate response for their condition. That being said, I do recognise that the trust’s performance against these standards needs to improve.
As I mentioned earlier, NHS England and NHS Improvement are working with the trust to help it to adapt to the new performance framework, and have also undertaken an independent service review of its operations. This review covers the trust’s demand and capacity modelling, staff recruitment and training, and its approach to pricing and contracting in order to enable it to meet the new ambulance response standards. The detail of this work is being finalised and will be presented to the trust board meeting in March.
With respect to the ambulance workforce, we are taking significant steps across the country to support staff. Compared to 2010, there are over 3,000 more paramedics in England. We agreed in December 2016 that NHS paramedics will be re-banded from band 5 to band 6 on the NHS pay scale. This moves paramedics significantly up the NHS salary structure, and helps to ensure that we are better able to recruit and retain staff in the future.
We are also working to support the trust in addressing issues with patient handovers to hospital trusts, which have been an issue in parts of the east of England. We are clear that handovers must take place within agreed timeframes, and we are supporting hospitals to ensure that improvements are made. As I noted earlier, the trust is working with hospitals to ensure adherence to the national guidance on handover delays. It has also deployed patient safety intervention teams to hospitals to undertake patient cohorting where significant hospital delays arise, as well as placing hospital ambulance liaison officers in emergency departments to help ambulance crews to respond more quickly to incoming calls.
I am conscious that the Minister is coming to the end of his contribution and that he is not able to respond, here and now, to all the issues I mentioned. Will he undertake to write to me on each and every one of the specific concerns that I raised, including the call for an independent governance review, so that we can get to the bottom of exactly what is happening?
I am very happy to give the right hon. Gentleman that commitment. Like me, the right hon. Gentleman wants to get a grip of this issue to ensure that it is addressed. I very much hear the concerns that he and other Members have raised. I hope that he can take some comfort from the series of actions that have already been put in place, including the risk assurance and the commission to Ministers, that signal the seriousness with which this issue is being addressed.
I would like to restate that we are taking the right hon. Gentleman’s concerns seriously. I have outlined the measures already taken as a result of the risk summit, and I will closely monitor the situation to ensure that these actions are delivered on. We have also discussed the wider initiatives that we are undertaking to improve ambulance services nationally, as well as specific local actions to ensure that patients receive the highest quality of care.
Again, I thank the right hon. Gentleman for introducing this debate. I hope that he, and indeed other Members who have serious concerns about this issue, will continue to work with me on a cross-party basis to ensure that all our constituents get the service that they rightly expect.
Question put and agreed to.
Motion made, and Question proposed, That this House do now adjourn.—(Rebecca Harris.)