The Minister of State, Department of Health (Mr Philip Dunne)
It is a pleasure, Madam Deputy Speaker, to join you a little earlier than anticipated and to have you in your place presiding over this important debate.
I congratulate my hon. Friend the Member for South Dorset (Richard Drax) on securing the debate. I am grateful for this opportunity to discuss ambulance response times and to put on the record, as he did, my thanks to all those who work in ambulance services across the country, not just in the south-west. Ambulance services are a vital part of the healthcare system and provide rapid assistance to people in urgent need of help. We are all united in expressing our gratitude to them for the professional work that they do.
I acknowledge that the NHS is busier than ever. That is why we are backing the NHS’s future plan with an extra £10 billion by 2020-21, providing some of the funding that my hon. Friend concluded his remarks by calling for. The ambulance service is experiencing unprecedented demand in all parts of the United Kingdom, including, as we heard from the hon. Member for Strangford (Jim Shannon), in Northern Ireland. It is delivering over 3,400 more emergency journeys every day in England than in 2010. In the past year, calls to ambulance services in England rose by 400,000, from 9 million in 2014-15 to 9.4 million in the year ending in April. Including calls transferred from NHS 111, ambulance services deal with more than 10 million 999 calls every year.
The demands currently being placed on ambulance trusts mean that performance targets have been, and continue to be, under pressure. South Western Ambulance Service NHS Foundation Trust has seen a particularly sharp increase in demand for its services. In the year to date, there have been 11% more calls in the south-west than at the same time last year. These calls have led to over 1,800 face-to-face responses by the service, on average, each and every day. In June this year, the Care Quality Commission inspected the service, and recently published the report of its findings. Overall, the trust has been awarded a rating of “requires improvement”. Within this rating, there were some positive findings. In particular, the trust was rated as outstanding for being a caring service, and the majority of feedback from patients about their individual experiences was favourable. However, it was also deemed to require improvement for its emergency operations centres, emergency and urgent care, and patient transport services, on which my hon. Friend focused.
I am sure my hon. Friend will be pleased to know that we are undertaking a range of initiatives to meet these challenges. Sir Bruce Keogh’s review of the NHS urgent and emergency care system is tackling the root causes of demand. Under that review, ambulance services will be transformed into mobile treatment centres. As a result of significant advances in technology in recent years, an ambulance presenting at a patient’s home, or to wherever it is called to treat them, is in a far better position to provide more care without, in many cases, the need to transfer them to hospital. There is greater use at the front end of “hear and treat”, which closes calls with advice over the phone, and “see and treat”, which treats patients on the scene without onward conveyance. This is all happening as a result of the greater integration with the rest of the health system that my hon. Friend called for. The CQC recognised the trust as one of the highest performing in England on “hear and treat”, which enables clinicians to assess and triage patients over the telephone and close the call without the need to send an ambulance.
As part of the wider review, under the ambulance response programme that my hon. Friend mentioned, NHS England is exploring ways in which to change responses to 999 calls by the ambulance service to help improve patient outcomes and help ambulance services better to manage demand. The first element of the ARP is “dispatch on disposition”, which was first piloted in London and in my hon. Friend’s local trust area in the south-west. “Dispatch on disposition” gives call handlers more time to make a clinical assessment of 999 calls that are not immediately life threatening, ensuring that the most appropriate response, based on clinical need, is sent to each incident first time. Early analysis shows benefits for patients from “dispatch on disposition”, and I have recently accepted advice from NHS England to extend this pilot to all trusts to help inform the independent evaluation.
My hon. Friend focused much of his speech on his, I think, personal aversion to targets, and on some of the perverse consequences that can arise. Under the second phase of the programme, we are piloting new clinical codes in ambulance services in Yorkshire, the west midlands and the south-west. The codes are used by ambulance services to determine the appropriate response for each emergency call they receive. The trial seeks to ensure clinically appropriate responses to each presenting condition while making the best use of our ambulance resources.
The programme has clinical leadership at its heart and will be independently evaluated by the School of Health and Related Research at the University of Sheffield, which my hon. Friend acknowledged. The evaluation report will be laid before Parliament once the Secretary of State has made a decision on whether any changes are needed to the ambulance standards. The most seriously ill patients will continue to receive an eight-minute response under the programme, and a pre-triage system is being used to ensure that life-threatening cases are identified quickly and efficiently. Good progress continues to be made with the programme and NHS England will make recommendations to Ministers in due course.
Richard Drax
My hon. Friend is very generous in giving way, especially after I had so much time. I have just one question. Yes, my natural instinct is against targets; I do not like them, but I understand why we have to have them. When ambulance trusts or hospitals are fined for not meeting targets, would it not be more logical to look into the reason why and ask the executives, whoever they may be, to sort it out? If they cannot do so, can we then sack them? If the conclusion is that it is a matter of giving more money to help towards achieving the target, obviously it should be given.
Mr Dunne
My hon. Friend will be aware that the clinical commissioning groups around the country commission services from ambulance trusts. I am sure he will have looked into the experience of the CCG in his constituency to see whether it believes it is getting the service that his constituents and its patients require. I can speak for my area, where a change to the disposition of response vehicles, particularly ambulances, was proposed by the ambulance service. A trial period took place, and the CCG was persuaded that it needed to provide more money to the ambulance service to fund additional crews to improve coverage. It is specific to individual areas, but CCGs need to work with ambulance trusts to ensure that the relevant standards are achieved.
The South Western Ambulance Service established an action plan in response to the CQC report to identify activities to improve its performance and demonstrate the benefits of the ARP, including addressing staffing and fleet requirements, and working with A&E departments in hospitals to which it conveys.
My hon. Friend made some startling observations about the challenges and consequences of extended handover times, and his examples were instructive. It is clearly a problem when ambulance crews are unable to discharge their patients into emergency departments as efficiently as they would like. NHS Improvement is working with local commissioners and trusts to tackle those problems, including handover delays, when they present a continuing problem. The amount of time lost to handover delays at hospitals is a significant concern in the south-west service, as he indicated. He mentioned an aggregate figure. The figure I have is that, on average, 60 hours per day were lost to handover delays in August 2016. In July, a regional workshop was run by NHS England and the Emergency Care Improvement Programme, attended by the South Western Ambulance Service, acute providers and commissioners. A set of actions to address handover delays were agreed upon and a plan to implement them is being developed. Hopefully he will see the benefit of that shortly.
We recognise that there is currently a shortage of paramedics nationally. As my hon. Friend mentioned, the south-west area is no exception. A number of initiatives are being implemented to address that, from recruitment campaigns for ambulance staff and paramedics, to training schemes to upskill the existing workforce. In the CQC report, it found that South Western Ambulance Service has an appropriate mix of skills to provide a safe service, and that, where staff numbers are below planned levels, the trust is making good efforts to recruit new staff.
At the end of September, there were 1,568 ambulance paramedics at the South Western Ambulance Service, almost double the number of ambulance paramedics there in 2010. That is an impressive achievement, but there remains a vacancy rate at the trust of just over 3%, equivalent to 134 members of full-time staff. Health Education England is working with the College of Paramedics and has invested more than £2 million in a two-year paramedic pre-degree pilot, through which potential paramedic students are recruited into roles providing structured care in urgent and emergency care settings. Health Education England is also providing funding to ambulance services to invest in their existing workforce, train ambulance technicians to become paramedics, and upskill paramedics to advanced or specialist paramedic level.
In the south-west, Health Education England has provided £350,000 in funding to help retain staff so that they stay longer than my hon. Friend indicated they have in the past, and to improve engagement and provide the opportunity to train with the very latest equipment. I am pleased to note that 100% of the trust’s rapid response vehicles and dual-crew ambulances are funded to have a paramedic on board. In the six months to May 2016 there was, on average, a paramedic on almost 92% of all A&E conveying vehicles. The service is approaching the level for which it is funded, and I hope those initiatives ensure that there are sufficient paramedics to hit that 100% target.
In addition, to help to reduce system pressures, NHS England is undertaking a public information campaign about urgent care services. My hon. Friend urged us to do that to encourage the public to present at the right place and do the right thing. In particular, he referred to the use of NHS 111 as a front door to the integrated urgent care system to help improve its credibility as the place to get initial advice, rather than people dialling 999.
To conclude, I again emphasise that ambulance services are vital to emergency care and the NHS as a whole. We all want to be sure that, where loved ones suffer heart attacks or are involved in a serious accident, they will not be left waiting for medical help to arrive. The initiatives being taken in response to the record demand facing the urgent and emergency care system will ensure that patients continue to receive the quality care that they need.
My hon. Friend concluded his remarks by asking for a new approach to the integration of NHS services, to which I would add the integration of NHS services with social care services. He could have been describing the sustainability and transformation plans that are currently being finalised by health areas across the country for presentation to NHS England by the end of this week. They are bottom-up plans prepared by clinicians and senior management within NHS organisations alongside local authority organisations responsible for social care, which is precisely what my hon. Friend called for. I am pleased to say that, under this Government, that is being delivered.
Question put and agreed to.