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The Lord Bishop of London
To ask His Majesty’s Government what progress they are making on ensuring swift ambulance handovers, as set out in Our Plan for Patients, published on 22 September, given the decision of ambulance workers across 11 trusts to ballot for strike action.
The Lord Bishop of London
My Lords, I start by saying how grateful I am to your Lordships’ House for setting time aside for what I think is an important and timely debate. I am also grateful for the briefing from the House of Lords Library.
Last week, the GMB union announced that it was balloting ambulance workers over strike action across 11 trusts in what would be the biggest ambulance workers’ strike for 30 years. I think it would be wise to ask ourselves what has happened across the whole system to bring us to this point. Ambulance handover delays are an increasing issue across the trusts in England. The NHS contract for this year sets out that 90% of handovers should take place within 30 minutes and 65% within 15. However, the Association of Ambulance Chief Executives notes 40,000 cases of patients waiting longer than an hour for handover—this was recorded this year and is the third-highest volume on record.
Long handover delays increase the risk of harm to patients while they are in ambulances. The NHS Confederation says that eight out of 10 patients who were delayed beyond 60 minutes were assessed as having had an experience that had potentially harmed them, and nearly one in 10 experienced severe harm as a result. The number of ambulances waiting to transfer their patients also impacts on the availability of ambulances, and the response times therefore increase. This in turn risks increasing further harm to those who are waiting for an ambulance in the community. Florence Nightingale famously once said that hospitals should do no harm. It is a sentiment that I believe is appropriate to the wider healthcare system. The healthcare system should do no harm.
Delays in handover also cause extreme anxiety for patients and families at a time when they are often very distressed. To be honest, waiting in an ambulance in this way is not how we should be treating people who have an inherent dignity. Long handovers are also putting pressure on staff and services right across the board. The Care Quality Commission’s annual report State of Care highlights the impact of waiting for handover on ambulance workers themselves. They cannot respond to incidents in the community. There may be a higher pressure on all staff involved, including call handlers who are trying to manage people who are repeatedly re-calling to check the status of their ambulance.
In addition to this, some ambulance workers are missing breaks and finishing their shifts late because they are required to stay with their patients as they wait to hand them over. These services function because people are working hard, even if they are not getting the resources that are required and the support they should be getting. The truth is that we cannot expect them to keep doing this.
The plan for patients set out by the former Secretary of State for Health and Social Care promised a “laser-like focus” on ambulance handover times. However, the plan that was set out lacked detail and made no headway in addressing the issue of workforce sustainability or retention. Will the Minister tell us when we can expect a workforce strategy to be published? A workforce strategy is key to any attempt to address this issue, which of course is one of the major issues facing the NHS and social care at this time.
The issue of ambulance handovers is one that gets to the heart of so many difficult issues which are within the health and social care sector. The NHS Confederation analysis of ambulance handovers states:
“Ambulance handover delays are not an ambulance issue, they are a whole-system issue and require a whole-system response.”
Some of the other issues that sit within the whole system are those we have discussed very recently in this House. They include, for example, the difficulty that people face in making a GP appointment. If you are unable to make a GP appointment, it may delay the time that you present, and therefore you become sicker. If you fail to be able to make a GP appointment, it may exacerbate the numbers of people who come to A&E.
There is also the significant issue of discharge into social care. The £500 million adult social care funding, announced by the then Secretary of State for Health and Social Care, was intended to assist with this. However, Matthew Taylor of the NHS Confederation has written to the Secretary of State, Steve Barclay, to say:
“Leaders across the NHS and local authorities are yet to see a single penny of this investment and any official detail on how it will be allocated”.
Change does not come quickly. Therefore, having the detail of this money and how it is to be allocated is important if we are going to avert a crisis this winter.
Furthermore, we have yet to understand whether this is not just an absorption of the health and social care levy repeal. As we discovered during the short passage of the Health and Social Care Levy (Repeal) Bill, the general budget is absorbing the loss of the tax increase so that the overall funding level for the health and social care sector does not change. Is it possible that this new £500 million for adult social care discharge fund is not new money, but is contributing to the absorption of the cut in the levy? I wonder whether the Minister could write to confirm the position.
I am sure noble Lords are aware that I have a particular concern for health inequalities. These inequalities are showing themselves in this area as well. The Care and Quality Commission annual report states that those living in the most deprived areas are likely to be more severely impacted by ambulance delays. It goes on to discuss the role of the ambulance service in meeting the needs of people caused by other failings across the sector:
“Anecdotal evidence … suggests that, traditionally, the ambulance service has fulfilled an informal role in helping people from deprived communities to navigate the health system”.
I have been fortunate recently to chair the Health Inequalities Action Group, which published its report last month. The report notes some of the barriers that both faith groups and healthcare workers face in engaging with each other, and the impact that would be possible with more constructive engagement, and the effect on reducing health inequalities. There is much work to be done to ensure that the more hidden groups, such as those known and represented by faith groups, can access the full benefit of healthcare available. If undertaken, this type of work will reduce pressure on the NHS, which, as a former Chief Nursing Officer for the Government, I feel is in crisis. This type of work, reducing health inequalities between healthcare and faith care workers, could also be part of a whole-system approach.
Ambulance handovers must be improved. However, without a workforce that is valued, supported and listened to, it is difficult to see how this is possible. In some ways, it is unsurprising that this balloting on action is being undertaken. According to the GMB acting national secretary, a third of ambulance workers think that a delay they have been involved with has led to a death. Can you imagine the impact that has on the well-being of healthcare and ambulance workers? Healthcare workers are also experiencing the cost of living crisis.
To draw to a close, what assessment have the Government made of the impact of ambulance waiting times on the loss of staff, and the loss of staff on ambulance waiting times? This will be the biggest ambulance workers’ strike for 30 years if it goes ahead, and this workforce is not in isolation. Last week, there was a further announcement of strikes across the NHS from UNISON. Yesterday, the Royal College of Nursing closed its UK-wide ballot for the first time for strike action in 106 years. The Royal College of Midwives and the Chartered Society of Physiotherapy are also balloting on strike action. It cannot be overstated how serious this is, not just for patients or our health but for the economic recovery of this country. This is a whole-systems problem which requires a whole-systems solution. I look forward to the contributions of other noble Lords and to the Minister’s response.
Baroness Brinton (LD)
My Lords, I declare my interest as a vice-president of the Local Government Association. I congratulate the right reverend Prelate the Bishop of London on securing this important debate and thank her for her thoughtful and knowledgeable introduction. I also echo her thanks to the House of Lords Library for its briefing and the Royal College of Nursing. It is important that we start by paying tribute to our ambulance and paramedic staff and, obviously, ambulance call handlers—as well as 111 staff, who may not automatically come into that category but are also fulfilling a very important role. All are doing the absolute best they can, despite the current circumstances. We owe them an enormous debt of gratitude.
We have had regular debates, Questions and Statements on the problems in our ambulance services for over a year now; everyone recognises that they are at breaking point. Record long ambulance waits are leaving vulnerable patients stuck outside hospitals waiting for the treatment they need. This debate rightly focuses on the part of the crisis that is very visible to everyone—ambulances queueing outside hospitals and delays in response times and handovers because A&E is full—and refers to the Government’s plan for patients.
I refer to the plan for patients because we have debated it within the last few weeks in your Lordships’ House, and most people recognise, as the plan does, that delays in the ambulance service are part of a larger problem—a “whole-systems problem” was the phrase I think the right reverend Prelate used. I will return to the detail of the plan later, but I start with some of the problems facing the ambulance service and its staff.
National standards set in 2017 said that calls are triaged into four categories depending on urgency and that all ambulance trusts must respond to 90% of category 3 calls within two hours and category 4 calls within three hours. I raise that because the targets for those categories have changed—they have lengthened.
Nationally, average ambulance wait times have more than doubled in the last two years. The British Heart Foundation, in a report published today, said that in September, average response times for category 2 calls—that is, suspected heart attacks and strokes—was 48 minutes, against the new target, set in spring this year, of 18 minutes. It used to be eight minutes before that.
I want to make a further point on category 1 and category 2 response times, because they also affect handover times and what is happening in A&E. For most levels of injury and illness, both category 1 and 2, there is what is known as the “golden hour” in which treatment must be started, particularly for strokes and suspected heart attacks. Strokes were moved into category 2 after paramedics started to be allowed to administer anti-clotting medication en route to hospital but, even with that extra time, you have to add on the queueing for hospitals. So, despite our talking about the waiting times for responses and the delays to handovers, that golden hour is constantly being eroded.
The Library briefing, to which the right reverend Prelate referred, made it plain that the situation continues to worsen. Ambulance handover delays are almost entirely caused by crowding in A&E, and that is why the plan for patients that the Government produced was discussed so heavily in your Lordships’ House. Part of the problem is that a lot of that is work that will happen in the future, not now. I want to ask the Minister what plans there are to upgrade the plan for patients, given the current crisis, because it is clear that this is unsustainable.
Today, a report in the Times on the British Heart Foundation report said that
“there had been 30,000 ‘excess’ deaths involving heart disease in England since the beginning of the pandemic.”
There is an absolute understanding that some of those are definitely due to ambulance delays. In fact, our papers are absolutely full of those reports and have been for the past six months.
The logjam could be described best in A&E as “beds and backlog”—and then there is care as well. The NHS Confederation helpfully identifies the problems of discharge and lack of capacity in the social care sector and has repeatedly, over the last year, asked the Government to help social care. Social care vacancies increased to 165,000 in July. That is a shocking increase of over 50% on the previous year, and the figure continues to rise.
It is increasingly difficult for disabled people who rely on personal assistants to recruit them. In your Lordships’ House, the noble Baronesses, Lady Campbell of Surbiton and Lady Thomas of Winchester, have repeatedly raised this. The same is true for people who need domiciliary care—that is, care in people’s homes—to keep them at home. It is increasingly difficult to recruit people to do that job. A key plank of the plan for patients is getting people home and keeping them there but that will not work without carers.
The consequences of Brexit are writ large in this sector. We know that the Government are trying to recruit from overseas, but we lost a stable workforce who returned home to Europe from the UK and have not, despite the problems of the pandemic, returned, even though they have been asked. The issue of delayed discharges therefore remains. I ask the Minister: what else on top of what was set out in the plan for patients will the Government introduce as a matter of urgency?
The broader problems in the NHS are also causing problems. From these Benches, we have highlighted for years the shortage of hospital beds compared to other OECD countries, which shows the UK at 2.3 beds per 1,000 of the population, compared to France at 5.7 and Germany at 12.6. It was a mistake to cut so many beds, especially without planning for and investing in primary care—not just GPs but all primary care healthcare professional staff and their support staff.
In August, when we were all on holiday, the Secretary of State announced that the Government would create the equivalent of 7,000 more beds through a mixture of new hospital beds, “virtual ward” spaces and initiatives to improve patient flow over the coming months. I have repeatedly asked Ministers for breakdowns of how many beds are in each of the various categories, but I still have not had an answer. There is a big difference between a bed, a virtual bed in somebody’s home, even with remote monitoring, and initiatives to improve patient flow—I am not quite sure how the latter equates to beds. It has been three months since this announcement, and we are already facing a rise in flu and other winter problems. Can the Minister please tell your Lordships’ House what that breakdown is and how many beds are in place? Specifically—I have asked him this before—can he say how many are virtual beds, because extra support is required in primary care to make those work? Will the Government undertake to fund more extra beds to stop handover delays at A&E and the backlog that goes right the way through the system?
I was very pleased to hear the right reverend Prelate refer to the importance of a workforce plan. We absolutely echo that from these Benches and have asked for one repeatedly, including during the passage of the Health and Care Bill earlier this year. This is not just about doctors and nurses, which the plan for patients relies on; it is also about other vital health care professionals such as physios, occupational therapists and speech and language therapists.
The plan for patients talks about more independent qualified prescribers in community pharmacies. This is essential to help reduce the burden on GPs. Exactly when will there be the promised increase in the number of independent qualified prescribers within community pharmacies? Will any long-term plans for providing finance and support for training and recruitment be brought forward? The plan for patients covers next year, but it is this winter that we have the problem. Above all, we need that workforce strategy.
My honourable friend Daisy Cooper MP said that Ministers should not lay the blame for these scandalous handover delays at the door of the NHS. To stop such delays, the Government need to fund the extra beds in A&E and properly fund social care. Hospitals are now running food banks for staff and staff cannot get to work because they cannot afford petrol for their cars. This is one of the reasons why staff are so concerned. This is not just about NHS staff possibly going on strike; this is an NHS cost of living strike. I hope the Minister can answer my questions.
Baroness Merron (Lab)
My Lords, I am glad to follow the noble Baroness, Lady Brinton, and I thank the right reverend Prelate for bringing not just this debate but great clarity to the issues it deals with.
In my view, the NHS faces what can only be described as a perfect storm in the making—except perfect it is not. The situation is absolutely dire and has been for many years; this is not a new problem. We have heard many times in your Lordships’ House about the well-documented challenges of getting an ambulance in an emergency. These challenges have served only to undermine the profound trust that the public ought to have in the National Health Service. In August alone, the Association of Ambulance Chief Executives estimated that around 35,000 patients were potentially at risk of harm as a result of long handover delays, with just under 4,000 of these experiencing potentially severe harm. There is no doubt that delay is the enemy of good care and safety.
As we have heard, delayed handovers are not just damaging in themselves. They result in poorer ambulance response times, as ambulances sit queueing outside A&E departments and cannot therefore get to patients waiting in the community. This increases pressure on not only clinical staff but ambulance call handlers, as the right reverend Prelate said, as distressed patients and their families call to get updates on their wait time, leading to thousands of duplicate calls and placing ever more pressure on ambulance services.
This situation now has all the potential to get even worse, with ambulance workers in 11 trusts balloting for strike action. If it does go ahead, it will be the biggest strike in that sector for some 30 years, which is surely nothing short of a disgrace. Union leaders have said that this is as much about patient safety as pay—and of course, when we talk about pay, we are doing so in the midst of a cost of living crisis. The right reverend Prelate asked the question: what has brought us to this point? I hope the Minister will reflect on that and perhaps give a view on it today to your Lordships’ House.
The general secretary of Unison, Christina McAnea, has said:
“Striking is the last thing dedicated health workers want to do. But with services in such a dire state, and staff struggling to deliver for patients with fewer colleagues than ever, many feel like the end of the road has been reached.”
Recently, the Minister advised nurses considering strike action to regard their work as a vocation. Can he give his view today on ambulance workers who are considering whether to go on strike? Indeed, can he give his views on the widespread balloting for strikes across the National Health Service, the factors he considers have led to this unrest, and whether they could have been avoided?
The Royal College of Emergency Medicine is clear that crowded hospitals is the operational issue stopping A&E doctors treating patients effectively and efficiently. As we know, high volumes of A&E attendances lead to overcrowding, rising pressure on services and a poorer experience for patients. Between April 2021 and March 2022, there were 24.4 million attendances at A&E across England, compared with 21.5 million in 2011-12. What assessment has been made of the reason for that increase, and could it have been avoided by taking action in other parts of the NHS, including on GP access?
It is fair to say that people desperately want to see an increase in the number of social care staff and beds, but perhaps it will be helpful if I emphasise that we are talking not just about beds but staffed beds, an increase in which would relieve the pressure. I add my voice to those of the right reverend Prelate and the noble Baroness, Lady Brinton, in asking a question that has been asked on so many occasions in your Lordships’ House: where is the workforce plan to deliver this increase in staff in the short, medium and long term? All of this is desperately needed.
Perhaps I may offer a helpful suggestion to the Minister: that the Government publish monthly the data, which is already being collected, showing the number of patients waiting two hours or more from the moment they step into the hospital, rather than simply when the doctor decides to admit them. It would be hugely helpful and give a much more accurate picture of patients’ actual experience in the accident and emergency department. Can the Minister take this up with his officials?
From Secretary of State Stephen Barclay saying that ambulance delays were a priority to Thérèse Coffey’s short-lived “ABCD” plan for patients, and now back to Stephen Barclay, it is fair to say that the sector is crying out for stability. Will the Minister indicate whether the plan for patients is still valid? Perhaps he might feel able to tell your Lordships’ House whether the new ministerial team have reviewed it and, if so, whether the Minister and his colleagues feel that the plan is sufficiently ambitious. It would be helpful for your Lordships’ House to have an update on this plan.
In my recent meeting with the Minister, for which I am grateful, he indicated that there are some 15 problem trusts that are especially struggling with ambulance delays. It would be helpful to receive an update on where the department’s work is on this and how lessons might be learned across the system, and for your Lordships’ House to know what action will be taken.
As we approach winter, what forecasting has been done on how the delays in these 15 trusts are likely to develop or change, and what will be done to avert the potential pressure of Covid and flu on these delays? I again emphasise the points about the £500 million adult social care discharge fund. Reports are that it is yet to be released to the health and social care system. Can the Minister say whether this is the case? If it is, why, and what is to be done?
Finally, what assessment have the UK Government made of the impact of current nursing vacancy rates on patient safety and emergency care? If an assessment has been made, can we have a publication of the modelling that has been done? Has there been a cost-benefit analysis of current spend on agency and international staff versus investing in recruitment and retention within our domestic workforce? As the right reverend Prelate said, this is not just about ambulances. This is a whole-system problem. I hope that the debate today will encourage the Minister to see it as such.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Markham) (Con)
My Lords, I am pleased to respond to this short debate. I reassure the right reverend Prelate the Bishop of London that ambulances are an utmost priority for this Government. We are absolutely committed to supporting the ambulance service to ensure that people receive the treatment that they need when they need it. However, as many noble Lords have noted, our ambulance services have faced unprecedented pressure since the pandemic, so I totally agree with the point that this is a whole-system issue, as the right reverend Prelate and the noble Baroness, Lady Merron, mentioned, and a “beds and backlog” issue, as the noble Baroness, Lady Brinton, mentioned. We all have similar variants on that. The plan for patients is still valid and is being reviewed by the current team. It is always being worked on and updated.
To directly address the point of the whole-system issue, or flow, some work that I have done has shown that the biggest predictor of ambulance wait times and handover times is bed occupancy. We all know that bed occupancy, which can be as high as 95%, with about 10% of our beds being taken up by Covid, is very much the issue. That is the first priority. Obviously, the Covid and flu vaccination programmes are important parts of that, but the £500 million adult social care fund to remove the 13% of bed blocking is vital to this.
I assure all the speakers who have mentioned it that the question of how the spend is allocated has been the subject of much debate, because we want to make sure that it really is targeted in the right place. Again, as a data hound, I wanted to make sure that we really were spending it in the best place. How it is spent now has been agreed, and that should be seen very quickly in the system.
The other issue regarding bed occupancy is, as the noble Baroness, Lady Brinton, mentioned, the 7,000 new beds. I am a big believer in the use of virtual wards, but I will get that breakdown so that we understand exactly what that situation is. I have been very much at the forefront of making sure that those 7,000 beds are targeted at the areas of most need, which is vital in all of this.
I think we all agree that dealing with the flow to create the space for A&E patients is the central issue. Primary care is a part of it too. That is why the 50 million increase in appointments is a vital part, as mentioned by the right reverend Prelate the Bishop of London and the noble Baronesses, Lady Merron and Lady Brinton. I will get the specific information on pharmacies as well.
On the workforce plan, work is being done on that right now. We are working from the 2020 NHS People Plan, and I will update the House as we get more information.
Central to the whole issue of ambulance handovers is, as I like to call it, the flow—the whole-system issue. It is only when we resolve bed occupancy and the flow into adult social care that we will have the free flow through the whole system and the reduction in handover times.
Response times were brought up by all the speakers. A lot of that is about managing the calls to achieve the right outcome. Yes, it means more call handlers, as was pointed out, so we are increasing the number of 999 call handlers to 2,500 and 111 call handlers to 4,800. I take the point made by the noble Baroness, Lady Brinton, about paying tribute to the work they are doing and the impact they make.
It is also about making sure that the call is navigated correctly. I was made aware of the fact—maybe this was known already—that 50% of 999 calls do not result in a conveyance to hospital. That says to me that there is a lot more we should be doing to help people in their home, such as picking up people from a fall and making sure that we go out quickly to their care homes. The thought is: in those instances, is an ambulance staffed with three people the best sort of response vehicle when someone needs help being put back on their feet? Maybe that is a much better place for us to use quick-response paramedic motorcycle-type people. This is very much at the top of our agenda. It is something that I was speaking to the NHS chair about just this week and something that I am going to do personally in terms of visits.
On the use of 111, unfortunately I had experience of that this week when my four year-old son was up all night throwing up and I was a distressed parent. My wife, like any mother would, was saying, “Should we be taking him to hospital? Should we be ringing 999?” We called 111 between midnight and 1 am. It took me a while to get through, so I am not saying it was a perfect experience, but when I spoke to them and they were able to put me in touch with a local doctor who could support me and get us through, that was key to helping us and stopped us going into A&E or clogging up 999.
Having the right people to deal with the problem in the right way is the best approach. It ensures that when there is an absolute emergency and you are into your golden hour, so to speak, the focus is really on having the right people. I shall not pretend that we have got it all right now but, believe me, it is very much at the top of the agenda. The investment in the ambulance fleet—we are talking about £20 million per year—is about making sure that we have the right type of vehicles to sort out the right situation, while ensuring that this is all overseen by a national ambulance co-ordination centre so that we really are responding in the correct way to each type of call and triaging, as mentioned.
I have mentioned the 15 trusts and 45% delays before; these were also mentioned by the noble Baroness, Lady Merron. I am very much into what the action plan is to address each of those. It is at the top of my agenda when I meet my NHS colleagues and I will give an update on where we are with that plan and our actions. To me, that is all part of an exercise to identify best practice and then roll it out across the system. As part of that, we have just kicked off a winter improvement collaboration programme that is about trying to identify those best practices and roll them out. That is the £450 million fund we are using; we have already used it to fund 120 trusts to create capacity in the system, such as in Leicester, north Bristol and Grimsby, so that we have those wait areas and can increase the capacity in the system. I am personally visiting some of the new system control centres in Maidstone next week, so that we can see what good really looks like and ensure that we are managing it as well as possible.
In addition, within the ambulance services themselves, we have put £150 million of increased funding into the system for these measures. It includes a lot of support, because a lot of these calls are from people who have mental health issues, so making sure that we have mental health-trained paramedics is a key part of this as well. These are all parts of the plan for patients, which is very much alive in all of this. However, as mentioned in the Question of the right reverend Prelate the Bishop of London and by the noble Baroness, Lady Merron, industrial action will clearly have an impact on everything we are trying to do here.
I note at this point that we have made the pay increases recommended by the pay review body at all points but I accept that if people are balloting to strike, there are clearly things we need to understand about why they feel the need to do that. It is premature to predict the outcome of the ballot at this time. We know that there is a range of options on the ballot, be it strike, work to rule or no strike, across three unions nationally and regionally. We are working on a number of contingency plans but, until we know the exact shape it will take, we cannot put those in place. Public and patient safety will come first and foremost; I know that is a view the ambulance staff share, which again is a point made by the noble Baroness, Lady Merron. When the ballot results are known, the NHS will sit down with the unions and staff to agree an approach with this in mind. They will agree the safe level of cover, which is foremost in all our minds, and then deploy our contingency plans around this safe level.
I hope I have managed to cover most of the points raised before I run out of time and sum up. Again, I will go over my notes to make sure that I follow up on any points I may have missed. I accept that this is an issue of key focus. I hope that the plans I have gone through this afternoon give a sense of what we are doing in this vital area. First and foremost, it is the whole-system issue, as mentioned by all the speakers today.
We recognise the pressures that the ambulance service and the wider NHS are facing. We continue to work closely with NHS England to ensure that patients receive the help they need when they need it. With that, I once again pay tribute to the right reverend Prelate the Bishop of London for securing this important debate. I know that we have a meeting soon, where I look forward to discussing this further.