Question for Short Debate
My Lords, there were a few moments during the last hour when I thought that some Members of your Lordships’ House might need medical attention and that my debate might be a welcome move on that part. In starting this debate, I welcome the noble Baroness, Lady Penn, back to the Front Bench. She has been otherwise occupied for the past few months; it is very good to see her back and looking so well.
I make no apology for returning to the subject of ambulance services. Not a week goes by when ambulance services are not in the headlines. Inevitably, when there are stories of distress and patients being left unattended, they do grab the headlines, but I hope that this evening we can do the job that this House really should do: go behind the headlines and look at the underlying factors, which are of enduring importance in determining the problems of and solutions for our ambulance services.
I am aware that a number of noble Lords are here again, having taken part in many debates on the Health and Care Bill. That piece of legislation is somewhat puzzling, frankly. Your Lordships’ House is now several days into Committee on that Bill, the purpose of which, so the Government tell us, is to lead to the better integration of health and social care in order to overcome health inequalities, as well as to move the National Health Service away from being a service that is largely reactive and acute to one that is much more about prevention and the promotion of well-being in communities. Yet we are considering the legislation without having seen either the White Paper on social care or the White Paper on integration, so it is all a bit Alice in Wonderland. If that feels confusing to us trying to do our job, as we have this debate, we might well hold in our minds those people in the ambulance service who are trying to build sustainable services that meet all its objectives and yet are having, sometimes day to day, to deal with competing demands and policy directions that are unclear.
We know that, at the moment, the ambulance service has a national framework and national targets. We also know that those are not being met. We know that national standards were set in 2017. Calls to the ambulance service are triaged into four categories, depending on the level of urgency. All ambulance trusts must respond to 90% of category 3 calls in two hours and category 4 calls in three hours. Nationally, ambulance waiting times have more than doubled in the past two years.
Very recent statistics from NHS England say that, on the level of demand in December 2021, per day, 29,800 calls to 999 were answered. That is 2% more than in November 2021, 9% more than in December 2019 and 22% more than in December 2020. On response times, in December 2021, the England average response time for category C1—the most urgent incidents—was 9.13 minutes; in the C1 90th centile, it was 16.12 minutes. So neither of them met the seven-minute mean or the 15-minute 90th centile standards that they were supposed to meet. For C2 in England, the average response time in December 2021 was 53.21 minutes and the 90th centile was one hour and 59 minutes, so the 18-minute and 40-minute standards were not met. The next statistics are due in February but it is unlikely, I suggest, that things will have changed dramatically in that time. The Government say that the NHS is under sustainable pressure, but I put it to noble Lords that these figures show that the pressure is not sustainable.
My colleague in another place, Daisy Cooper, met the British Heart Foundation last week, and it made a really interesting point. Not only are ambulance times slow but it had examples of heart patients who called the hotline because paramedics had turned up to stabilise them on site and then left them for an even more important job, asking family members to take them or leaving them at home so as not to take them into hospital at all. Were we to drill down, we would find a lot more of that kind of statistical manipulation going on behind those average national statistics.
My friend Helen Morgan, who I am delighted to say is the new MP for North Shropshire, has been doing a lot of work on the problems in her constituency. It is a large rural constituency in which four ambulance hubs have been removed and there have recently been waits of over seven hours to hand over patients at Shropshire hospitals. That is not unusual, but it is unacceptable.
We know what the problems are because organisations such as NHS Providers have told us. Problems with admissions to A&E are most often because A&E beds are blocked by people who cannot be moved out into the rest of the hospital, because beds in other wards are being blocked by people who are well enough to go home but for whom there are no social care packages.
There are three things that the Government could and should do. First, they should make sure that the data on hospital waiting times is much more rigorous, timely and defined. At the moment we are being given average national data, which is not helping us to plan and, most importantly, to configure services.
Secondly, we need to increase social care funding. Everyone knows across the NHS that, although money has gone into the NHS—as indeed it should—it is absolutely clear that unless and until there is investment in social care all these blockages in the NHS will continue to happen.
Finally, rather than continuing to treat the ambulance service as an afterthought—a simple way of getting people between one acute service and another—the Government should look at a paper that was recently produced by Public Health England and the Association of Ambulance Chief Executives. It is about developing the ambulance service as a public health service by equipping and training ambulance staff to note what is happening when they go on site to find people and the causes of incidents. They could then develop that dataset, some of which they already have from call centres, and use technology that is coming online, such as AI, to begin to predict with much more detail the demands on the ambulance service. That would enable it to work not just with acute hospitals but social services departments, the police and others and to become much more refined at predicting incidents and demand. It is only by managing demand and bringing it down that we will build an ambulance service that is sustainable in the longer term.
I would love to talk about the use of the ambulance service for mental health, but I do not have the time.
One final thing: during the last two years of Covid, the ambulance service has been kept afloat by St John Ambulance. What are the Government doing to make sure that St John Ambulance remains sustainable over the coming months?
I declare my interest as a non-executive director of Chesterfield Royal Hospital NHS Foundation Trust. I too welcome the Minister back to the Front Bench. I hope that this first outing is not as difficult as the last set of amendments was for her noble friend Lady Williams.
I thank my noble friend Lady Barker for securing this debate, which is important and necessary, considering the issues that many people and communities face with their ambulance services at present. This is despite the dedicated professionalism of so many people who work to try to save lives and deal with some of the most vulnerable people. Rather, it is a reflection of the way in which our healthcare system is struggling to meet the demands of the population it serves.
This debate must not be about just statistics but people—those who require the services of the ambulance service and those many thousands of individuals who work for the ambulance service and do their best in providing professional first response and medical services when people are in their greatest need. I want to bring to the attention of the House one such family and the distressing phone call a man in his 20s had to make when he woke up and found his mother struggling for breath. In that call, he can be heard telling ambulance call handlers that his mother, from Ashton-under-Lyne in Greater Manchester, was struggling to breathe after she woke up screaming his name in the early hours of the morning. He describes how her situation is critical, only to be told that he may well have to wait for one and a half hours for an ambulance to arrive because the service is busy.
The man rings back later and says that his mother’s mouth has gone white and pleads for immediate assistance, but emergency service personnel can tell him only that help is on the way. Another call is made after his mother collapses and becomes unresponsive. Her heartbroken son can be heard venting his anger that an ambulance did not arrive in time to save her. He tells the call handlers, “I rang an hour ago for an ambulance. She’s had difficulty breathing, and now she’s dead. My mother is dead.” When paramedics finally arrived at nearly 3.30 am, almost an hour after his initial call, they tried to revive his mum but attempts, sadly, failed. Unfortunately, this is not a one-off tragic event but is happening to many families across the country.
Therefore, I ask the Minister what she would say, on a human level, to those families who see a loved one die or see serious health implications for members of their family when an ambulance does not arrive. We must not hide behind statistics: these are real people and the effect of not having an effective ambulance service is that people are dying and families are shattered.
This debate is not about a quick fix for the ambulance service but indicates that the Government must move to a more person-centred approach to the care system. It is no good looking at why ambulances are not able to respond speedily without dealing with why they have to wait up to 10 hours outside hospital admissions doors because people in A&E cannot move into a hospital bed as 10% to 30% of those beds are occupied by people who are medically fit to be discharged but do not have a care package in place, so they cannot be discharged out of the discharge door of the hospital.
Just putting more money into the ambulance service, as welcome as that is, will not solve this crisis in a sustainable way. A key question around this systematic issue is: when are the Government going to bring forward well-thought-out and fully costed long-term plans to deal with the social care issues that keep over half a million bed days a year blocked due to people not being able to move when they are ready for medical discharge?
Another knock-on effect, which would help solve the ambulance crisis, is caused by the problems in general practice. The Government know that many GPs feel burned out and are working incredibly long hours, but many are retiring because of the workload. General practice is becoming the first port of call for many medical and social problems. When people find it hard to get a GP’s appointment in a timely manner, they ring the ambulance service, knowing that they will receive some form of medical intervention. So the question is: what are the plans for dealing with GP services so that people can get a timely appointment and GPs do not feel that they have to retire because their work/life balance is not in kilter?
The University of Sheffield, in March 2020, produced a very good paper: Reducing Avoidable Ambulance Conveyancing in England: Interventions and Associated Evidence. That paper comes up with many solutions, and a lot of them are about integration, which my noble friend Lady Barker talked about. I will ask some questions. If we are seriously talking about intervention, what is the Government’s thinking about doing away with individual ambulance trusts? Why are they not part of health provider trusts so the innovation can come and the walls between those who are part of first responder services in health and those who provide care services are removed and they are integrated rather than seen as separate legal entities? Would the Government be open to that kind of integration and to saying that it does not have to be a separate ambulance trust?
What is the Government’s working—particularly in line with that paper from the University of Sheffield—on mental health issues? The evidence shows that quite a lot of the conveyancing of people with mental health issues via an ambulance took place only because there were not community services for those suffering from mental health issues. Where is the investment? Where is the government thinking on that? This is not an ambulance crisis but an issue to do with our health service not being able to meet demand or not being prepared for dealing with the requirements of the modern healthcare system.
These issues will take time, so there has to be a much more immediate response. It is clear that the £55 million that the Government introduced in July is not enough to tackle the problems. So, finally, let me ask the Minister: what plans above the £55 million do the Government have, and when will they be implemented, to ensure that in the interim enough staff, ambulances, equipment and expertise are available for responding paramedics so that no one else has to make a heart-wrenching phone call that ends with a loved one dying, as the young man in Greater Manchester had to do, seeing his mum take her last breath because an ambulance was not able to get to them in time?
My Lords, I too congratulate the noble Baroness, Lady Barker, on securing this important debate and welcome the noble Baroness, Lady Penn, back to her place on the Front Bench.
The subject of tonight’s debate is literally a matter of life and death for too many people at the moment, and while most of our debate so far has been about statistics, health policy and hospitals, and much of the debate will refer to those strategic issues, at the heart of it is the key ambulance service that we have all come to expect by our sides at the worst times in our lives to rescue us and get us emergency help. This debate is all about how our paramedics and their colleagues save lives day after day, and I pay tribute to them.
However, it is also about patients and how they have come to expect that their ambulance service will be there for them. I thank the Library for its excellent briefing and also the TUC for its report on The NHS Workforce Crisis—a Decade in the Making, which has a couple of interesting facts about the current pressures that paramedics and ambulance service personnel are under.
As we have heard, the national standards were set in 2017. Calls are triaged into four categories, and I want to make a further point on response times for categories 1 and 2, which my noble friend Lady Barker alluded to. For most levels of injury and illness in categories 1 and 2, there is a golden hour in which treatment needs to be started at hospital to help survival. Strokes used to be in category 1, along with heart attacks and cardiac arrests, but were moved into category 2 after, fairly recently, paramedics were allowed to administer clot-busting medication en route to hospital. Unfortunately, however, even with that extra bit of time, now there is extra queuing time outside hospitals, ensuring that patients are delayed in getting into A&E.
Before Christmas, I asked Questions on the crisis in the Cornwall Ambulance Service. At one point, there were more patients queuing in ambulances outside A&E at the Royal Cornwall Hospital in Truro than there were beds in A&E—all of which were already full. Five days ago, once again more than 20 ambulances were queuing. The consequences for patients and ambulance service staff of working under such permanent pressure are difficult. For patients in the middle of a major medical crisis, seeing ambulances arrive and paramedics assisting and then, sometimes, having to watch them depart again to leave for a more urgent case is very distressing.
For staff, as outlined in the TUC report, there are intense frustrations and stress at not being able to do properly the job that they love and have trained for. Once admitted to A&E, patients have been left on trolleys for hours while staff waiting with them are unable to get on with other jobs. Steve, aged 21, a clinical care manager in the ambulance service, said:
“Ten years ago, paramedics would do between 12-14 jobs in one shift, but now many paramedics have to stand in corridors with patients for hours. I've known”
“staff to wait in a corridor for up to four hours.”
On delayed discharges, Cornwall recently sought to solve its problems by paying families £1,200 to take their loved ones home because there were no social care beds available either. The TUC report confirms the stress to staff. It says:
“In the NHS, anxiety, stress, depression and”—[Inaudible]
But it is really important to understand that the stress and depression are absolutely appalling and result in time being taken off on sick leave by ambulance staff and others.
My noble friend Lord Scriven talked about the problems of delayed discharges and workforce—[Inaudible.] In another place, MPs Daisy Cooper and Helen Morgan jointly wrote to the Health Secretary on the crisis in our ambulance services. They wrote:
“This year the Association of Ambulance Chief Executives found that 160,000 people a year are coming to harm, of whom 12,000 have experienced ‘severe harm’, because of the issues impacting ambulances.”
Helen Morgan, the new MP for North Shropshire, has also asked the Government to commission an investigation into the ambulance service crisis in Shropshire, where strategic decisions to close ambulance stations have led to severe problems. There have been deaths among those kept waiting. Before Christmas, one man who lived just three miles from the hospital waited 10 hours for an ambulance that did not turn up.
Yesterday, an Answer from Health Minister Edward Argar to a Written Question from Daisy Cooper about the number of ambulance services at REAP level 4 in England said that
“nine ambulance services were at Level 4 REAP.”
That rather emollient Answer means that all but one of the ambulance services are still under the highest levels of pressure. In responding to recent Questions in your Lordships’ House, the Health Minister has repeatedly told noble Lords of the funding that will come to increase the workforce. But this problem is more complex. As with other clinical and healthcare professionals, recruitment and training does not solve an emergency overnight. Care homes, hospitals, delayed discharges—as we have heard—and pressures on A&E are all causing pressures on ambulance services.
Along with the exceptional work of St John Ambulance volunteers, many of our service personnel have been assisting ambulance services during recent months, but this was always intended only as a temporary measure. My noble friend Lady Barker outlined four key actions that would help, so I ask the Minister: what urgent actions will the Government take to reduce the logjam in our hospitals and care homes so that A&E and ambulances can once again come to the aid of people in an emergency, whether accident or illness? This is a real crisis for our ambulance services that needs help now.
My Lords, I too extend a welcome back to the noble Baroness, Lady Penn, and offer congratulations to her and her family. I hope she finds her return to the House as positive an experience as I am sure the new addition to her family has been. I am grateful to the noble Baroness, Lady Barker, for securing this important debate and for emphasising the importance of integration in our health services, of which ambulance services are a key part.
I start by paying tribute to the staff in the ambulance services, not just those in the ambulances themselves but those who support the ambulance crew—from those in the control room, who use their skill to answer calls, reassure the caller and get the service to the right place, through to those who support the ambulance services to do their job by maintaining the vehicle fleet, cooking, cleaning and supporting in so many other ways. I also add my thanks to the volunteers of the St John Ambulance brigade and members of the Armed Forces who were deployed to alleviate ambulance staff shortages related to Covid-19.
As we have heard throughout this debate, there is intense pressure on ambulance services, and staff are struggling and patients suffering. Our health and care services were already weakened and exposed by inadequate levels of funding when the pandemic hit. As a result, the NHS now faces unprecedented challenges. Just last week, the Royal College of Emergency Medicine warned that patients will come to “avoidable harm” in A&Es across the country, estimating that over 4,500 patients are likely to have died during 2020-21 after waiting more than 12 hours in emergency departments.
As we have heard in this debate, the NHS in England has set a national target for ambulances to respond to the most life-threatening incidents within seven minutes on average. However, NHS figures show that the average response time in December for ambulances dealing with the most urgent incidents—defined as calls from people with life-threatening illnesses or injuries—was nine minutes and 13 seconds. This comes in at just under the average response time of nine minutes and 20 seconds in October, which was the longest since current records began in August 2017.
Ambulances also took an average of 53 minutes and 21 seconds to respond to emergency calls dealing with matters such as burns, epilepsy and strokes, which was the second longest time on record. Response times for urgent calls such as late stages of labour, non-severe burns and diabetes averaged two hours, 51 minutes and eight seconds—again, the second longest time on record. NHS England also said that staff dealt with the highest ever number of call-outs relating to life-threatening situations last month, averaging one every 33 seconds. One can only imagine what it is like for someone in pain and distress, and for those standing by, to wait for an inordinate length of time. After all, ambulances respond when there is an urgent need, whatever the grade of the urgency.
Unsurprisingly, the College of Paramedics has said that apologising to patients for long waits is the first thing paramedics are doing when they walk through the door. The latest figures show that nearly one in four patients arriving at hospitals in England by ambulance waited at least 30 minutes to be handed over to A&E departments. NHS England figures show that 18,307 delays of half an hour or more were recorded across all hospital trusts in the seven days to 9 January, which represents 23% of all arrivals by ambulance.
When asked what can be done to relieve the pressure, the College of Paramedics said that, in the short term, there are a number of ambulances that wait outside hospitals to hand over the care of a patient and are therefore not available in the community, as we have heard in this debate. What joined-up action is there to reduce handover delays? Has the Minister reviewed whether there is a need for more paramedics?
NHS workers have been warning for many months that the service is under strain due to a combination of waning workforce, Covid, respiratory infections, a backlog of patients and a build-up of health problems over lockdown. The Royal College of Emergency Medicine has been calling for months for a response from Ministers to provide short-term and long-term solutions. We have debated during the passage of the Health and Care Bill the vital need for workforce planning. What planning is there to ensure that the ambulance service has the right number of properly trained staff?
I am absolutely sure that the Minister will refer to the additional funding announced in July last year by NHS England to improve response times. I note that NHS England said at the time that the money would be shared by NHS trusts
“based on the number of patients they serve locally”,
with trusts being given discretion on how best to use the funding to increase staff numbers. What assessment has been made of what has happened across the country, and to what effect? What assessment has been made of the difference in response times that the additional funding has made? I understand that the Minister will need to write to me on this point, but I would be interested to know, on a trust by trust basis, how many additional staff are in control rooms and on the front line. How many additional ambulances were on the road during the winter as the result of this increase in funding?
Lastly, may I press the Minister on a matter which the noble Lord, Lord Scriven, raised, regarding prevention rather cure? What steps have been taken to avoid unnecessary ambulance calls and visits to A&E? How has NHS 111 done in respect of recruiting additional staff? How have GPs expanded their capacity, particularly in view of what we know about low morale and GPs leaving the service?
The Opposition wrote to the Secretary of State in August of last year outlining some of the terrible situations this pressure on ambulance services is leading to, and asking what the Government were doing to support the ambulance service to do its vital work. That question remains, and I look forward to the Minister’s response.
My Lords, I thank noble Lords for their warm welcome; it is great to be back. I also thank the noble Baroness, Lady Barker, for securing a debate on such an important topic, as my first debate back in this House. I join all noble Lords in expressing my gratitude for the outstanding work done by ambulance service staff and the wider NHS in what are often difficult circumstances.
Before we get into the details of statistics, funding and plans, it is important to address the question, asked by the noble Lord, Lord Scriven, of what I would say on a human level to those who have been affected by delays, often in tragic circumstances. All I can say is that I am sorry and that, while I will explain in more detail the circumstances in which these delays occurred and what we are doing to address them, the Government are clear that, while the delays are explicable, they are certainly not acceptable and we are doing all we can to improve the situation we face.
As noble Lords have acknowledged, ambulance services have faced extraordinary pressure over the last 18 months. The pandemic has placed significant demands on the service. In December 2021, the service answered almost 1 million calls, an increase of 22% on December 2020. While 999 calls tend to highlight demand related to more serious medical conditions, many ambulance services are also responsible for 111 calls, which, in November 2021, increased by just over 20% compared to November 2019.
Infection prevention and control measures, higher instances of delays in the handover of ambulance patients to A&E, as many noble Lords have noted, tying up ambulances in queues and delaying the response to new calls, and high workforce sickness absence rates, are all affecting the service. This combination of factors has placed unprecedented stress on the service and driven increased response times to patients in the community. Despite these pressures, performance for category 1 calls—the most serious calls, which are classified as life-threatening—has now been largely maintained at around nine minutes on average over several months, despite a 16% increase in these calls compared to before the pandemic. However, there have been significant increases in response times against the other categories, and even in category 1 we are not meeting the targets that we have set ourselves.
We must improve performance, and therefore we have put in place a number of measures. We have invested £55 million in staffing capacity to manage winter pressures up to March. All trusts are receiving part of this funding, which will increase call handling and operational response capacity, boosting staff numbers by 700. The noble Baroness, Lady Merron, asked about a breakdown of some of those figures on a trust-by-trust basis. I do not have them to hand, but I will see whether they exist and I can get them for her. The noble Baroness, Lady Brinton, referred to the pressure on ambulance staff in these circumstances. We recognise that and have put in place improved health and well-being support from NHSE and NHSI for ambulance trusts, with £1.75 million being invested to support the well-being of front-line ambulance staff during these pressures.
Almost all noble Lords noted that delays in handover are a big part of this picture. Targeted support to the most challenged hospitals to improve their patient handover processes has been put in place, helping ambulances swiftly to get back out on the road. This is focused on the most challenged hospital sites, where delays are predominantly concentrated. The 29 acute trusts operating the most challenged sites are responsible for 60% of the 60 minute-plus handover delays. As several noble Lords have said, it is not a uniform picture across the country and more data on a trust-by-trust level will help us to draw that picture out further.
We have also made a £4.4 million capital investment to keep an additional 154 ambulances on the road this winter, and a £75 million investment in NHS 111 to boost staff numbers by 1,100, boosting call-taking and clinical advice capacity to better help patients at home and avoid unnecessary ambulance calls and trips to A&E. There is continuous central monitoring and support to ambulance trusts from NHSEI’s national ambulance co-ordination centre, and we have also made significant long-term investments in the ambulance workforce. The number of NHS ambulance staff and support staff has increased by 38% since July 2010.
It is also right to recognise the contribution of the ambulance service in managing the demands of the pandemic on the wider health service. Ambulance services link the whole of the NHS, providing an interface between primary, community and secondary care. At a time when the NHS is facing unprecedented demand, ambulance services are absorbing some of that increase, treating more people over the phone and finding ways to reduce the pressure on other services. With clinical support in control rooms, for example, the ambulance service is closing 12% of 999 calls with clinical advice over the phone, which is up from 7.4% in December 2019, saving valuable ambulance resources to respond to more urgent calls.
The noble Baroness, Lady Barker, raised a number of points in her opening speech, reflected in the comments by other noble Lords, about how the challenges that the ambulance service is facing are symptomatic of wider challenges, not just within the NHS, but in social care, and looking at what we are doing to address that integration.
The Government published their plan on social care in December last year, and the integration White Paper is expected early this year, so those pieces of work will be updated. However, progress on those issues is not waiting for further White Papers to published.
In September last year, we committed to investing an additional £5.4 billion over three years to begin a comprehensive reform programme on social care. That is on top of funding in previous years, particularly to address—for example, through the better care fund—delayed discharges, which are having a knock-on effect across the NHS.
We have talked a bit about the statistics, and noble Lords said that there was not much sign of hope. I would not overstate the signs of hope we can take from some of the statistics, but one noble Lord mentioned the REAP status of ambulance trusts, and I have some updated figures on that since the Parliamentary Answer that was provided in the Commons. Since 22 January, the West Midlands Ambulance Service has moved to REAP level 3 and has remained there. The North East Ambulance Service moved to REAP level 3 on 25 January and remains there. Also, in the week to 19 January, category 2 responses have improved to an average of 31 minutes.
That performance is still significantly longer than the current target but might be a sign that some of the investment we have been putting since we announced further support last summer is having an effect on the ground. We are continuing to recruit and improve the numbers of call handlers and 111 handlers, for example.
I have addressed handover delays. There were three things on the wish list of the noble Baroness, Lady Barker, speaking for those who work in the service and, more widely, those who are close to the pressures they are facing. On more rigorous and timely hospital data, I have committed to write to the noble Baroness, Lady Merron, if I have any more trust-by-trust data on the resources being put in. I undertake to look if there is anything further I can say on that.
Increasing social care funding and social care reform is getting under way. I am sure the Government will look closely at the great point about developing the ambulance service as a public health service, which sees the causes of incidents on site. Ambulance service trusts have sophisticated demand modelling processes to look at some of those issues.
The noble Baroness also mentioned the excellent work done by St John Ambulance during the pandemic, to which I pay tribute. NHS England and NHS Improvement have contracted St John Ambulance to provide support to ambulance trusts throughout the pandemic, and they continue to work with St John on its continuing role in the future.
The noble Lord, Lord Scriven, raised the question of whether individual ambulance trusts might be reformed as part of the wider reform picture. I am not aware of any plans to do that, but it is an interesting point that I will take back to the department. He also mentioned mental health; the Government have put increased investment into that in recent years. There is more to do, but one example is community crisis cafes, an alternative place where people who may be in a mental health crisis can go that is not A&E and does not involve calling out an ambulance. They are safe spaces where people can get the help they need. The Government have put more funding into those kinds of services, and I am sure that they will continue to do so.
I am short on time, so I will close by reiterating the Government’s support for the ambulance service. Ministers are in regular contact with NHSEI on the performance of the emergency care system, including the ambulance service, and will continue to provide the support the NHS needs to ensure that patients receive the help they need, when they need it.
Once again, I thank the noble Baroness, who has rightly raised this important issue and secured such a thoughtful and interesting debate, if a shorter one than that on the Bill to which we will return.