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Ambulance Waiting Times: Royal Cornwall Hospital

Volume 717: debated on Wednesday 29 June 2022

Motion made, and Question proposed, That this House do now adjourn.—(Mr Marcus Jones.)

This issue of ambulance waiting times at the Royal Cornwall Hospital is vital to my constituents and the whole of Cornwall. I want to start by thanking all health and social care colleagues for their hard work. They work with such professionalism, dedication and selflessness, despite being short-staffed and under immense pressure. It is telling that the constituents who write to me on these issues include praise for the staff who have helped them with such compassion and care in their time of need. Over the past 12 months, I, alongside my five Cornish MP colleagues, have had many meetings with NHS leaders and other Cornish healthcare stakeholders to discuss these challenges. We have also written to Ministers to highlight individual cases and the wider situation on numerous occasions, and I appreciate this opportunity to again highlight the situation in Cornwall to Ministers.

Ambulance waiting times at the Royal Cornwall Hospital are an increasing concern, with the hospital recently recording the worst ambulance wait times in the country, topping the list for the proportion of arrivals that were delayed by more than an hour, at 41%; this represents 10% of the wait times in the whole of England. There is widespread consensus that ambulance response times are slow in Cornwall due to handover delays. The Royal Cornwall Hospital has the highest percentage of handovers over 60 minutes, at 25%. That is particularly concerning, given that the NHS standard contract states that all handovers of patients between ambulances and accident and emergency should take place within 15 minutes, with none taking more than 30 minutes. These handover delays of over 15 minutes have contributed to an average of 255 ambulance hours lost every day in May. I receive several emails each week from constituents who have experienced these delays first hand. One such constituent wrote recently that they were transferred by ambulance to the RCH in the early afternoon. On arrival, there were 15 other ambulances already waiting for their patients to be admitted. During the afternoon, evening and night, they were transferred to five other ambulances and crews. The various categories of ambulances offered stretcher beds of varying levels of discomfort, and there was a shortage of blankets, no access to food and no toilet facilities. They were eventually admitted to the emergency department at around 5 the following morning.

Delayed handovers result in poorer ambulance response times, as ambulances queue outside A&E unable to attend patients waiting in the community. That leaves patients at increased risk of delays in diagnosis and treatment, and compromises the ability to respond to serious incidents. These delays also increase pressure on clinical staff and on ambulance service call handlers, who look after distressed patients and their families, who call again and again, desperate to hear their wait time. That can lead to thousands of additional calls, placing even more pressure on the service. Constituents have told me that they have waited 13 hours for an ambulance and that they have called many times in the interim to chase an update on the expected arrival time.

Let me be clear: these delays are not to do with ambulance service call handlers; they are a whole-system issue and are impacted by acute challenges elsewhere in the system, particularly with hospital capacity and patient flow. The issues include delayed discharges to social care and other services, as well as bed occupancy. As such, a whole-system approach is needed to tackle this issue.

This issue is important not only in Cornwall but in Plymouth, because Derriford Hospital serves part of Cornwall, providing some of the ambulances she mentioned. She is right that this is not the fault of the people who drive the ambulances or who dispatch them, but does she agree that it is utterly unsustainable that many ambulance crews may get only one shout per shift, because they spend the remainder of the shift queuing outside an emergency department in Cornwall or Plymouth waiting to hand over their patient? That is simply unsustainable if we are to have the NHS recovery we need in the south-west.

I thank the hon. Gentleman for his intervention, and he is absolutely right. He will know that, purely because of their geography, hospitals in Cornwall and Devon rely on each other, and the ambulance crews go between the two. He is also right that this is a multifaceted issue. Hopefully I will cover most of it in my speech and the Minister will respond knowing that there are many things we need to do to try to tackle it.

In Cornwall the capacity challenges stem partly from the hangover from the covid-19 restrictions. Predominantly, however, they are about staffing, which hinders our social care system’s ability to safely assess and care for patients at the rate necessary to clear the beds in the hospitals. On a single day last month, 190 beds in Cornwall were occupied by patients awaiting discharge into social care. Those patients had no medical need to be in those beds. Thankfully the number has now fallen below 130, but the issue remains that too many people are staying in hospital beds because of discharge challenges.

In March the Care Quality Commission inspected the whole of the Cornwall and the Isles of Scilly urgent and emergency care system. The report states:

“Delays in ambulance response times in Cornwall are extremely concerning and pose a high level of risk to patient safety. Ambulance handover delays at hospitals in the region were some of the highest recorded in England. This resulted in people being treated in the ambulances outside of the hospital, it also meant a significant reduction in the number of ambulances available to respond to 999 calls. These delays impacted on the safe care and treatment people received and posed a high risk to people awaiting a 999 response…Delays in discharge from acute medical care impacted on patient flow across urgent and emergency care pathways. This also resulted in delays in handovers from ambulance crews, prolonged waits and overcrowding in the Emergency Department due to the lack of bed capacity.”

The report goes on to state:

“Without significant improvement in patient flow and better collaborative working between health and social care, it is unlikely that patient safety and performance across urgent and emergency care will improve.”

That is key. Although we have seen some pilots and seen community services adapt to meet changes in demand, additional focus on health promotion and preventive healthcare is needed to support people to manage their own health needs.

The report also identified that adult social care in Cornwall has had one of the highest short staff shortage rates in the entire country. That directly affects the ability to discharge patients into the social care sector, as well as A&E and ambulance response times.

During the by-election campaign in Tiverton and Honiton, almost everybody I spoke to on the doorstep had their own personal story about having to wait for an ambulance. This is not the fault of ambulance crews, but it is absolutely the system-wide issue that the hon. Member describes. Does she agree that what we really need is a community ambulance fund to alleviate some of the pressures we are experiencing in the south-west, given that we have the longest ambulance waiting times in the country?

I thank the hon. Gentleman for his intervention, and welcome him to the House for his first contribution. He will be aware that the CCG is responsible for distributing and commissioning services within his area. Therefore, this is not something that Ministers should have to implement. He should lobby his own CCG if he thinks that that is a beneficial service for his area.

The report also identified that adult social care in Cornwall has one of the highest rates of staff shortages in the entire country. It is right that the hospital has a comprehensive handover delay improvement plan that aims to maintain patient safety, to ensure the health and safety of trust staff and to promote effective joint working. These will cover key areas including: incidents management; reporting and external reviews; internal and external communication; data quality; and joint handover escalation plans.

The CCG is also taking positive action, working with the Conservative Cornwall Council, to use commission spend to try to bring more reablement workers online with more flexible care across Cornwall. In addition, it is plugging gaps in domiciliary care in central and mid-Cornwall, and in district nursing teams. Seventy five reablement workers will come online from November, and they are working with Health Education England to transfer their apprenticeship levy so that it is possible to employ even more people across Cornwall.

The CCG is also identifying young people who might want to stay in Cornwall. It has been learning from the work on recruitment fairs of the University Hospitals Plymouth NHS Trust, which is in the constituency of the hon. Member for Plymouth, Sutton and Devonport (Luke Pollard), and which has successfully attracted young people in Plymouth wishing to remain in the area.

In addition, the CCG is ensuring that joined-up, accessible care in local communities is treated as a priority, responding to local needs with the inclusion of NHS services, organisations and charities. The new integrated care board, which meets for the first time on Friday, will utilise existing assets in the community to improve the availability of care services.

It is also right that the providers of the Integrated Urgent Care Service have been commissioned for a six-month pilot to test new methods for handling incoming calls. This involves ensuring that low priority calls are being assessed by a clinician, such as a GP, and in turn being directed to the most appropriate setting for treatment and care. The initial phases of the pilot have provided a clear demonstration of positive outcomes for patients, showing a 71% reduction in the need for ambulances, so it is right that it is upscaling this approach to continue to reduce demand on the ambulance service.

Another trial aims to remove ambulance need for non-injury falls, by ensuring that calls are pulled from the call stack and passed to the IUCS call centre in Truro, where a dispatcher can dispatch a resource from the independent ambulance service. This means that where someone has fallen but is not at risk from an injury that might mean they should not be moved, they are attended and settled into a more comfortable place within their own home. They then have a follow-up referral with a community team, which aims to identify why they fell, allowing it to put in place safeguards to prevent reoccurrence. Early data has shown that, in positive cases, where paramedics have responded and assessed, the person is placed back in bed in their own home within an hour.

I am also pleased that the CCG is working on the vital development of facilities at Bodmin Hospital, including the development of the urgent treatment centre, the community assessment and treatment unit and the diagnostic hub, which will all contribute to reducing the care pressures that Cornwall faces and the pressure on the RCHT.

The next few weeks see the standing down of the CCG and the standing up of the integrated care system, which will provide a much more collaborative approach to the healthcare system. As a new MP, I will be grateful for that, because, learning on the job means that we have to learn what board does what, and now there will be just one board that is accountable. I am also grateful to the Government for already taking a range of actions to tackle this issue. In 2020, I was delighted that the hospital had £42.5million-worth of debt written off as part of the Government’s announcement to reset NHS finances. After NHS England announced its goal for a seven-minute average for ambulance response time, the Government stepped in with a £55 million investment in the NHS, helping to provide 700 additional staff in control rooms and on the frontline to improve response times.

That is alongside £4.4 million to keep an additional 154 ambulances on the road over the winter. In addition, NHS 111 is recruiting an extra 1,100 staff. Moreover a £250 million winter GP capacity fund will help to avoid unnecessary ambulance calls and visits to A&E. The Government are also right to have taken the difficult decision, which was unpopular in some corners, to implement the 1.25% health and social care levy, raising £12 billion a year on average over the next three years to fix the social care crisis.

Despite that progress, we still have an alarming situation, which is why the Government must look at all options to tackle the problem. They must look urgently at tackling the staffing shortages preventing us from moving patients out of hospital beds and into domiciliary care. Constituents who are already being cared for at home are seeing a reduction in care packages due to staff shortages, which will clearly have a cumulative effect on trying to discharge hospital patients.

Cornwall has recently been found to have the country’s most understaffed social care system, with ongoing challenges around recruitment and retention. Employers in the space compete for staff with the hospitality and retail sectors, with cost of living increases and housing affordability and availability problems adding to the weight of issues. I should add that that was the case before the pandemic, but it has been compounded by the effect of covid and we see it acutely now.

We must advertise care as a profession and a career path, not just a job. We should look at creative new measures to make the profession more attractive, improve the workplace culture, tackle burnout and offer higher salaries. We must also ensure staff can afford to rent or buy affordably in the area by tackling the housing crisis and promoting key worker housing. The Government must also recognise the challenges of rurality, an ageing population, higher demand for services and the hangover from covid, which have all contributed to this issue. I believe we should also increase the number of first responders in rural areas and look at the model of the parish nurse; both are vital to the local village I live in.

Reducing ambulance waiting times at the Royal Cornwall Hospital is an urgent issue for the people of Cornwall. I look forward to working with the Government on a range of solutions available to improve the situation, and of course the Minister is always welcome to come and visit.

I congratulate my hon. Friend the Member for Truro and Falmouth (Cherilyn Mackrory) on securing this important debate. Since her election, she has been a notable advocate both in this House and more privately with Ministers on behalf of her constituents and those who work in her local healthcare system—as, indeed, are all six Members of Parliament representing seats in Cornwall.

May I also take the opportunity—I know we do not always use this sort of language now, but I will—to congratulate the hon. and gallant Member for Tiverton and Honiton (Richard Foord) both on his election to this House and on his contribution to the debate this evening. I look forward to his maiden speech, but it is a privilege for me to have had the opportunity, I think, to be the first Minister to respond to him and congratulate him. It is always a pleasure to see the hon. Member for Plymouth, Sutton and Devonport (Luke Pollard), who may not be my hon. Friend but is my friend. I thank him for his contribution, highlighting the issues at Derriford Hospital.

As my hon. Friend the Member for Truro and Falmouth has made clear, there are complex causes behind the challenges faced by her constituents and those of other right hon. and hon. Members around the country with ambulance services and ambulance response times. As she will know, ambulance services faced significant pressures during the pandemic and continue to do so. I join her and Members on both sides of the House in putting on record, as she did, our gratitude to all the ambulance service staff and the NHS for their outstanding work, both at this time and particularly in recent years.

The service is still working under exceptional demand and pressures. In May 2022, the ambulance service answered more than 850,000 calls, an increase of 7% on May 2021 figures. Those are national figures; I will turn to my hon. Friend’s local situation in Cornwall in due course. She is right to highlight that the issue is not just with the ambulance service itself, although that is often the visual manifestation or symptom of broader challenges within the health ecosystem and the pressures it is under. It is about handovers and the ability do turnarounds and get the ambulances back on the road, having had a patient safely admitted to the A&E department in an acute setting. I will turn to that in a moment too. As she will be aware, other issues as well as demand impact on performance, including, still, although less so than there have been, elements of infection prevention and control measures. There are issues in particular areas with staff absence—for example, still, where there is an outbreak of covid. She also highlighted some very specific local factors that I will turn to.

Touching on that, I am aware of the local context that my hon. Friend set out, in that in Cornwall the demand for NHS services has combined with wider systemic issues, placing particular stress on the system. Some of those local factors include the demographic challenges of the age profile of the population and difficulties or challenges in securing the adult social care capacity to meet current and projected demand. I suspect that much of what I say about Cornwall will apply to Devon as well, as the context both demographically and in terms of patterns of demand are not completely dissimilar.

Other factors that play a key part include geography and, as my hon. Friend highlighted, the cost of living, affordable housing, and the ability to retain a skilled workforce. It is also worth remembering, in the context of Cornwall, that whereas many parts of the NHS system see very pressured demand over the winter period that tends to ease somewhat during the summer, allowing them time and space, Cornwall, and, I suspect, Devon as well, being such popular holiday destinations, see a different range of challenges and pressures on the system as holidaymakers come into to area and often need to use these services. I am very sensitive to that point.

I assure my hon. Friend, who touched on some of those issues, that significant work is under way across the entire local health and care system to improve patient flow through the hospital, which is the key element in making the system work smoothly to reduce the wait times for emergency care and reduce the numbers of delays in handing ambulance patients over to A&E. Importantly, the NHS Kernow clinical commissioning group, as it currently is—as she rightly highlighted, as of 1 July ICSs become statutory bodies—is continuing to work with all providers to create and commission additional capacity, including a plan to release 80 additional hospital beds now and 20 to 40 further beds in time for the winter. This will help to increase the flow of patients out of the emergency department, reducing overcrowding and the numbers of ambulance-patient handover delays. I pay tribute to my hon. Friend for the summit that she and local Cornwall Members convened with me earlier in the year not only to talk about the pressures faced by the system at the time but to begin looking forward to how we can mitigate future pressures.

The trust is expanding the use of virtual wards whereby patients are monitored remotely at home rather than being admitted to hospital. This further reduces pressure on local bed capacity and allows for patients to be safely treated at home, which can be beneficial for their recovery. Of course, that is done on the basis of clinical triage and assessment. There has also been an increase in the adult social care domiciliary care pay rate, helping to generate more social care capacity locally and ensure that patients are able to be discharged from hospital to home as soon as they are medically fit. That is supported by the Proud to Care recruitment campaign. I understand that the NHS and Cornwall Council are aiming to launch a targeted campaign in the autumn to encourage more under-25s to work in the care sector.

I now turn to discharge. I have highlighted some of the action that is being taken locally to improve patient flow through hospitals by discharging patients more quickly. The aim is partly to increase the number of discharges a day, but it is also to bring more discharges forward to earlier in the day, when it is clinically safe to do so, thus making those discharges much better managed. It is important that all partners work well together on that. At a national level, we have set up a national discharge taskforce. As Minister, I now get weekly statistics about where we are on delayed discharges. My hon. Friend alluded to the number of people who are clinically fit for discharge but have not been discharged, for a variety of reasons. Reducing that by even a small proportion would have a significant impact on the availability of beds and thus patient flow. It is a complex picture with a variety of reasons behind delayed discharges. However, it is important that we continue to work across the system locally and with national support to get the number of delayed discharges down.

The CCG locally is also establishing community assessment and treatment units for frail and elderly patients as an alternative to hospital admission, alongside an innovative reablement ward that is now moving to a community hospital location, as my hon. Friend mentioned, as a permanent model of care. Taken together, these interventions will help to ensure the effective flow of patients through hospital, reducing those waiting times and crucially reducing the number of ambulance handover delays, allowing ambulances to get back on the road more rapidly.

To address the wider issues around staff recruitment and retention, the NHS is working with local partners on schemes to address cost of living concerns, including work with the Supportmatch charity on the homeshare scheme, where a householder helps to offer affordable accommodation to someone working in the sector. There is the new guardianship programme developed by Supportmatch, NHS England and NHS Improvement in the south-west that enables householders to offer a spare room to fully vetted and checked health and care workers. Typical agreements can run from two months to two years. We should recognise those sorts of innovations that have grown up locally for the beneficial effects they can have.

It is also encouraging to see that these measures are delivering improvements. Performance against the four-hour A&E standard improved from 76.9% meeting that in April to just shy of 80% meeting it in May. There is more to do, clearly, but that is a positive direction of travel. The South Western Ambulance Service also saw notable improvements across all response time categories in May compared with April, including a 24-minute reduction in the average category 2 response time. Again, there is still more to do to get those down to target levels, but that is a positive step and a positive direction of travel.

There was a reduction of more than one minute in the average response time to the most serious category 1 calls. That does not sound like a huge amount, but in April, when we were seeing challenges, that was a bit over 11 minutes. Shaving a minute off that is still hugely important. There is more to do to get it down to the circa six or seven minutes that it was in May 2019, before the pandemic. We have further to go, but we are focused upon it.

Then there is investment in hospitals locally. In this context, I highlight the £1.3 million in 2020-21 of the elective recovery estates funding, the £2 million for technology to help elective recovery, the £2.8 million for A&E upgrades and the £1.7 million previously given to tackle the backlog maintenance in my hon. Friend’s trust. I pay tribute to her, but I pay particular tribute to my hon. Friends the Members for North Cornwall (Scott Mann) and for St Austell and Newquay (Steve Double), who in the nature of their roles in this place are not able to intervene directly in this debate. It is important that I put on record their work on behalf of their constituents in lobbying Ministers and securing that investment from Government in their local hospital trust.

There is a wide range of national support in place to improve ambulance performance more widely.

According to the South Western Ambulance Service, three of the five hospitals in the country with the longest ambulance waiting and hand-over times are south-west hospitals—Derriford, Bristol and Royal Cornwall. Is there something south-west specific that the Minister needs to look at as to why south-west hospitals are experiencing the longest hand-overs?

I gently say to the hon. Gentleman that the hon. Member for North Shropshire (Helen Morgan) made the point about delays in respect of her county in March, so we are seeing significant challenges across the country. I have highlighted some of the specific points about Cornwall, such as the geography and the distances. It is also about demand, which, as I alluded to, does not abate even slightly in the summer. There is a range of factors—my hon. Friend the Member for Truro and Falmouth highlighted a number of them—and I have set out some of the measures that we are taking to address them.

Nationally, as my hon. Friend alluded to, a wide range of support is in place. Ambulance trusts receive continuous central monitoring and support from the National Ambulance Coordination Centre, and NHSEI has allocated £150 million of additional system funding for ambulance service pressures in 2022-23, which will support improvements to response times through additional call handler recruitment, retention and other funding pressures.

National 999 call handler numbers have been boosted to more than 2,300 at the start of May 2022, which is about 400 more than in September 2021, with further potential increases. We are also investing £20 million of capital funding in ambulance trusts in each of the three financial years to 2024-25, in addition to the £50 million national investment across NHS 111.

We continue to work closely, in terms of additional resources and system pressures, with the ambulance trusts in the south-west and across the country. I am grateful to my hon. Friend for highlighting this hugely important issue. Her constituents are lucky to have her representing them in this place. I will continue to work with her and other right hon. and hon. Members, and the system, to deliver the improvements that we all wish to continue seeing.

I, too, welcome Mr Foord to the House on his maiden intervention—if such terminology exists; it does now.

Question put and agreed to.

House adjourned.