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arbitrate when a clinical judgment has been made? He is saying, in effect, "I shall have the final say as to whether a service shall be provided."

The result of this arbitrary action is that those who are least able to speak up for themselves are the most affected, in Warrington and the rest of Cheshire. I am of course referring to the sick, elderly, infirm and disabled. It is having a devastating effect on those people.

I do not have time to cite the many examples that I have. So I will give two, as reported in the Warrington Guardian of 30 March. In the first case, that newspaper wrote :

"Hospital staff said that out-patient services have been minimised to stretcher cases only. One out-patient, who has just had his right leg amputated, was told he is not eligible for transport and must continue making his own way to hospital. The 71-year-old ex-serviceman, secretary of Culcheth Royal British Legion, told the Guardian : I have just been fitted with an artificial leg and have to visit a physiotherapist every week to learn how to use it. I also make regular visits to the Artificial Limb and Appliance Centre in Liverpool and am continually having to depend on friends. This is a very desperate situation.' ".

Clearly, such a man is covered by the guidelines and should have been provided with transport.

In the second case, the paper wrote :

"Another woman aged 72 was refused an ambulance to have an artificial leg fitted in Liverpool. She had no friends or relatives to help, and was forced to cancel the appointment and manage without."

Nobody--least of all the Minister, knowing him as I do--would try to justify that state of affairs or what is happening to the out-patient vehicle service in Cheshire and particularly in Warrington. How ill does a person have to be to qualify for an out-patient vehicle in the area? Why are those concerned not abiding by the guidelines, particularly when, it seems, the decision no longer rests with the members of the clinical profession but with accountants and faceless bureaucrats, such as the unit general manager? They should be obliged to live up to the guidelines laid down by the Department. We must not forget the effect that all this will have on jobs. The non-emergency ambulance staff, because of the reduced number of vehicles in Cheshire, are not fully deployed, even if they are fully paid. If those members of staff are not being deployed, redundancies are bound to result. Indeed, as many as 60 drivers in Cheshire could be made redundant, and nine of them will be in Warrington. During the ambulance dispute, half the non-qualified ambulance staff were put on temporary contracts. Their services will be dispensed with as soon as the management finds it convenient to take that step. Penny-pinching of this kind must not take place at the expense of the sick and those in need. The cuts should cease immediately, and I hope the Minister will announce that from tonight, full out-patient transport services will be restored.

12.4 am

The Parliamentary Under-Secretary of State for Health (Mr. Roger Freeman) : I am grateful to the hon. Member for Warrington, North (Mr. Hoyle) for the kind remarks which he made at the outset of this brief debate. The hon. Gentleman thanked me for staying. I am always pleased to reply to debates that he initiates, but the hon. Gentleman is the only person present who has any choice in the matter. You, Mr. Deputy Speaker, and the only other person present in the Chamber apart from myself--my

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hon. Friend the Member for Reading, West (Mr. Durant)--have no choice in the matter. Nevertheless, I am grateful for the hon. Gentleman's remarks.

The hon. Member for Warrington, North concentrated on out-patient ambulance services and upon the consequences for the patient of the changes that I shall describe in a moment, rather than the consequences upon the unions. He was fair to do that, and I shall therefore concentrate on the consequences for patients.

Since 1982, the Chester health authority has managed a single ambulance service for all five district health authorities in Cheshire--Chester, Crewe, Halton, Macclesfield and Warrington. It has run that service efficiently, and has introduced diesel vehicles, paramedic training and cardiac care training. A lot more needs to be done, but the authority is to be congratulated on the start that it has made.

As with all other ambulance services throughout the country, there are two fairly distinct aspects to the service. The first and most important is the need to respond promptly to accidents and emergencies--or 999 calls--to meet doctors' requests for urgent admissions and to move patients who need to be transferred from one hospital to another. These can, quite literally, be a matter of life and death, and it is entirely right that the utmost priority should be given to that side of the service. Recent events have underlined the importance that the public attach to the accident and emergency service. The other aspect is the routine transportation of outpatients to and from hospital or treatment centres. That is clearly the service which the hon. Member is most concerned about. When we talk of routine cases, we have to distinguish between patients who have a medical dependency, such as oxygen therapy or who may need to be lifted in and out of their homes--those are clinically necessary services which are provided by the Cheshire ambulance service--and those patients who simply need a transport service to and from hospital. I say "simply", but of course that transport service is important, particularly for those people who need some form of public transport because they do not possess a car, or because it is to far to walk to and from the hospital.

In the examples which I have cited, where there is a clear clinical necessity, the service is clearly needed and will continue to be provided. However, the social need for transport is not a function of the ambulance service.

The hon. Gentleman has pressed me to define what is meant by clinically necessary services in his health authority and, most importantly, who defines what those services should be.

Before the ambulance dispute, I am told, the Cheshire service had 37 ambulances available as emergency ambulances but very often only between 12 and 14 were available, as quite a number--clearly the majority--were being used for non-accident and non-emergency work. Clearly that was unsatisfactory, because the accident and emergency service can, and I understand in some cases did, suffer.

Now the fleet of ambulances in Cheshire has been modernised. Some 20 ambulances are dedicated to accident and emergency work and there are some 22 other vehicles for non-accident and non-emergency work. I am told that those mainly comprise 10 to 12-seater vehicles.

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The numbers will grow marginally in the future to some 22 ambulances dedicated to emergency work and some 24 for non-emergency work.

A new system has been introduced for financing the ambulance service in Cheshire from 1 April this year. The proposals were under consideration before the dispute began but are only now being introduced.

The amount retained at the Chester headquarters for the accident and emergency service proper is some £4 million for 1990-91, and approximately £1.2 million has been allocated to the five districts. They will use that sum to purchase non-accident and emergency services either centrally from the Cheshire ambulance service--I have indicated the vehicles that could be available--or locally. The key requirement still is that the services provided must be clinically necessary.

Locally, there will be patient transport managers in the districts, to assess the needs for non-accident and emergency work--always concentrating on the clinical need for such services.

The hon. Gentleman asked the perfectly fair question : to what extent is authority delegated to those managers for making clinical judgments? I do not expect them to make clinical judgments. That is not their function. The responsibility for making the decision as to whether or not a patient is, for clinical or medical reasons, in need of transport rests with the medical staff, not the managers--who are there to manage the service and to match resources against clinical need.

It may help if I explain the reasoning behind the proposals. Until recently, during the day there have been about 37 ambulances theoretically available as a maximum for accident and emergency duties, but only one third of those could really be called on if needed. The other two thirds have been engaged on routine duties such as planned admissions to hospital or carrying out-patients to and from treatment centres. Not only has that reduced the number of vehicles available for emergencies, but it has been wasteful of resources to deploy fully trained and equipped crews on duties that could easily be carried out by personnel with less training, in simpler vehicles.

While Cheshire has managed overall to meet the minimum times laid down nationally for responding to an accident or emergency call, the position at individual stations has often been dangerously near, or actually below, the mark. This has put a considerable strain on the service. At night, at weekends, and during the "quiet hours", the level of emergency cover has stood at only 17 ambulances. Taking into account the geographical spread of Cheshire and the network of motorways that intersperses the county, that is very sparse cover. Demand has sometimes meant that even ambulances reserved for accident and emergency duties have been called upon to deal with planned journeys involving patients discharged from, or being admitted to, hospital. It is for these reasons that the working party studying the needs of the Cheshire ambulance service has recommended a two-tier service. That does not mean a first and second-class service. The proposal is for a distinct accident and emergency service with the very latest equipment and with staff trained to the highest level, able to perform a range of life- saving techniques--and, it must be said, with more dedicated vehicles.

The non-emergency ambulance service will continue to transport patients with a medical need as determined by a clinician. That service, as organised by Chester for the

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county of Cheshire, will be available to the districts. They will have freedom either to purchase services from Chester or to make their own local decisions.

There may be patients who can make their own way to and from hospital but who find difficulty meeting the cost of travel. They can apply for help with these costs and should ask the hospital about this. The Department of health leaflet H11, "NHS Hospital Travel Costs", explains who can claim help with fares incurred travelling to and from hospital and how the scheme works. There is also a Cheshire dial-a-ride service for registered disabled.

That is our mechanism for providing help in a social context for those who cannot afford the full costs of travelling to or from hospital.

Mr. Hoyle : The dial-a-ride service does not provide that, nor was it set up to do so. Its purpose is to provide vehicles, not for travel to hospital, but for disabled and other people who need to go shopping and so on. There cannot be help from that service, because it is already stretched to the limit.

Mr. Freeman : I am grateful to the hon. Gentleman ; I stand corrected. The record will show that it is a service available within the community and not to and from hospital. I am not familiar with the service, but doubtless next time I am in Cheshire I shall make detailed inquiries about it.

I should make it clear that geriatric day care attendances, with which there were, I understand, some problems during the recent dispute, will be given priority, as will other cases which in the light of individual circumstances merit special attention. I am talking now about the non- accident and emergency services. The intention is to use the available resources to best effect and to make sure that those who really need the service obtain it--that is, those with a clinical need--as promptly as possible.

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The working party has also recommended that ambulance stations provide more flexible and appropriate cover throughout the country. It has recommended that there should be a redistribution of resources to provide 22 emergency ambulances during the day and 20 at night. This will improve cover in the Crewe, Ellsmere Port, Malpas and Warrington areas. These recommendations are aimed at strengthening the accident and emergency service and providing overall a service more tailored to the needs of the people who use it.

Mr. Hoyle : There are two points I should like the Minister to explain. Why was there no consultation with anyone, and particularly with the community health council? I am willing to give the Minister a copy of the document. How can he say all these things when Mr. Lloyd, divisional commander, control, says plainly that there has been no increase in the level of provision operative during the national dispute?

Mr. Freeman : I do not know to which document the hon Gentleman is referring. I look forward to receiving a copy from him. I shall certainly look into the point about consultation procedure. I shall also send copies of the Official Report to region and district for additional comment.

As I understand it, this is a reorganised service which concentrates the resources on accident and emergency and which does not diminish the proper service which should be provided for those who have a clinical need for transportation. It means, perhaps, that those with no clinical need who were using the service will no longer be able to do so. I believe that it concentrates resources where they are most needed in the hon. Gentleman's constituency. I think that is best, not only for his constituents but for the Health Service as a whole.

Question put and agreed to.

Adjourned accordingly at seventeen minutes past Twelve o'clock midnight.

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