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Ambulance Service

12 noon

Ms Joan Walley (Stoke-on-Trent, North): I am glad to have this opportunity to discuss best practice in the ambulance service, which has an excellent record in Staffordshire, where my constituency and that of my hon. Friend the Member for Staffordshire, Moorlands (Charlotte Atkins) are located. I also speak as someone who avidly watches "Casualty" every Saturday night.

A "Panorama" investigation that was broadcast on 17 January raised important questions about training, the pre-emergency hospital care that is available throughout the country and the management of the national health service ambulance service. That programme, which was criticised for concentrating on six incidents that I shall not discuss, shed a spotlight on wider issues, including the differences in ambulance services and training and response times between regions. I hope that we can discuss those matters constructively. The Government need to consider their response to the disparities in standards and performance that the "Panorama" programme highlighted.

I want to put Staffordshire's record straight and to discuss with the Under-Secretary of State for Health, my hon. Friend the Member for Birmingham, Edgbaston (Ms Stuart), whether Britain can benefit from my county's best practice and what best practice should be applied throughout the country. Ministers recognised in paraliamentary answers that were given to me in February 1998 and to my hon. Friend the Member for Staffordshire, Moorlands in July 1998 that the Staffordshire ambulance service is a beacon. My county's approach should be in the main stream. My county's performance could help the Government to develop new standards.

Service provision in Staffordshire will be subject to an independent audit by the Sheffield university medical care research unit. We shall know, when that audit is published, whether the practice in Staffordshire could help to influence ambulance service provision. When we need an ambulance, it is important that we get it quickly and that it has a suitably qualified and experienced crew. I pay tribute to the work of paramedics and ambulance service crews across the country. We must ensure that they receive appropriate training and management and that they have career prospects that will help them to deliver the services that the public want.

What scope is there for ensuring greater standardisation of best practice? I want to ensure that there is a higher minimum standard; I do not want to stifle local variations and regional differences, which contribute to the overall performance of the ambulance service. That higher minimum standard would ensure that regional disparities were better understood and resourced and that all services were levelled upwards. Paramedics are about to become a state-registered profession run by a board that will operate under the Council for Professions Supplementary to Medicine. What progress--I ask this in a spirit of constructive criticism--has been made in that regard? Will the new way of organising paramedics in the ambulance service contain sufficient powers to ensure that they can do the job that the public expect them to do?

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I turn to the training of paramedics. I do not doubt their commitment and dedication, but do we offer enough? For example, compared to the training offered by other countries, or that offered to military technicians in our defence services, we could perhaps offer more. The standard of paramedic training in the United Kingdom is far below that required for emergency medical technicians and paramedics in the United States, Canada, Australia, New Zealand and South Africa. We must consider best practice not only across the country but internationally.

We must also consider national funding, and the structures and mechanisms that are needed to improve training. How is that process being reviewed? I am slightly worried by research conducted at Sheffield university, which suggests that there is a detrimental variation in treatment offered by ambulance crews.

Should not greater attention be given to various clinical protocols throughout the country? On the "Panorama" programme, Barry John, who is chairman of the Ambulance Service Association, admitted that some services do not use best practice at the moment. We must ensure that the association is able to achieve best practice.

Some counties authorise certain life-saving drugs and others do not. Paramedics in some counties are trained in life-saving techniques and others are not. Is there any longer an excuse for such variations? In the light of the fact that three counties that have different protocols have merged to form an east midlands trust, the time has come for a national minimum standard.

Does the Minister agree that now is the time to rethink the new targets that will be linked to core prioritisation by April 2001? I recognise that progress has been made, but core prioritisation studies and the achievements revealed by Department of Health statistics make it clear that not all pilot projects have met the new national standards. New priority dispatch ambulance performance standards have been adopted. The aim is that 75 per cent. of category A calls--emergencies--will be responded to within 8 minutes, and 95 per cent. of all other calls will be responded to within 14 minutes. However, in adopting those standards and targets, are we not going backwards? Only Staffordshire ambulance trust has met them.

We should examine best practice and assess whether it can be applied elsewhere. We should consider implementing a system of modelling that has helped to identify peak demand areas and plan staff deployment, thereby providing better standards across the country. We should learn lessons from that, and from the target response times that have consistently been met during the past four years. I am worried that we are adopting a two-tier response system. Two out of eight pilot ambulance services have been unable to meet their targets. Time must be taken to assess that problem before further progress can be made.

During the time remaining, I shall focus on achievements in Staffordshire. Of course, we have wonderful crews and paramedics, a good working relationship with Staffordshire's Members of Parliament, input from trade unions and an enormous

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amount of community liaison work taking place every day throughout the country. I refer particularly to the 40 automated exterior defibrillators that we have in Staffordshire, and I support The Observer campaign for more defibrillators and put in a request for at least two more in north Staffordshire.

Under the Staffordshire partnership, about 1,000 pupils every year are trained in first aid by the ambulance trust. The lunchtime for lifeline programme offers training in first aid for those in industry and other workplaces. Above all, Staffordshire's records and response times far exceed those of anywhere else in the country and if we can achieve them, why cannot other places do so?

I pay tribute to the work that has been done to win Staffordshire a beacon award. The award is a standard of excellence for the retirement and retention scheme, which enables those ambulance workers who cannot continue working full-time to return, but to work different hours. That is an example of good personnel work. I also congratulate the Staffordshire ambulance service on winning a charter mark award for providing quality services.

All those factors can be linked to the modernisation programme that the new Labour Government want to put into place. I would be the first to accept that we cannot always get it right. Certainly, Staffordshire has had problems with the health authority's specification for its patient transport service, and it has proved difficult to meet response time targets. However, the new system that Staffordshire is modelling would benefit the rest of the country. I would like to see much closer links between hospitals and general practitioners and GP trusts. If a new category of beacon award is wanted, the North Staffordshire hospital trust primary group, which is seeking trust status, could act as a pilot scheme.

The time is now right to take stock and scrutinise. Above all, it is time to involve the professionals, the managers and the unions, who work so hard for the ambulance service. I invite my hon. Friend the Minister to visit Staffordshire. We have been visited by ambulance service personnel and Ministers from all around the world, most recently from New South Wales. I would be very happy if a member of the new Labour Government could visit Staffordshire and discuss those matters in detail with Staffordshire's Members of Parliament.

12.12 pm

Charlotte Atkins (Staffordshire, Moorlands): I congratulate my hon. Friend the Member for Stoke-on-Trent, North (Ms Walley) on securing this important debate, and thank her for allowing me a little share of it. As my hon. Friend said, Staffordshire ambulance service has achieved outstanding results. What surprised me about the "Panorama" programme was the reluctance of the service nationally to explore the reasons for Staffordshire's success. It is no surprise to Staffordshire's Members of Parliament, but it must be incomprehensible to many others.

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The changes in Staffordshire were brought about with considerable angst. Inevitably, staff were reluctant to be thrown out of their comfortable ambulance stations, but the results speak for themselves. Ultimately, all ambulance staff want to perform at their best. They are professionals who want to see a job well done.

We have a national health service that has national standards and national training courses. Why do we not have a national ambulance service? As we saw on "Panorama", different ambulance services make different drugs available. Each service purchases its own ambulances. That purchasing policy produces no economies of scale, and some services have made bad mistakes. There seems to be little exchange of ideas when it comes to choosing the right vehicles for such an essential job.

As my hon. Friend suggested, the most significant factor for patients is the absence of nationally funded training. Each ambulance trust has to fund its own training. Staff have to pay back their training costs to the trust if they leave the job. I cannot imagine nurses having to pay back the costs of their training when they find new posts at other hospitals. That might not be a problem if, as the "Panorama" programme suggested, training for paramedics lasted only six weeks, but it does not. Initially, basic grade ambulance technicians have six weeks' training, after which they work with an experienced person for one year. The technicians are then tested on their confidence and undertake practical and written tests. After a further two years, all prospective paramedics must pass a stringent examination before being accepted for training. Only then do they undertake six weeks' introductory training. They have also to undergo a series of study days during the following year.

Prospective paramedics are accepted as qualified paramedics only when they pass written and practical examinations. They are tested by consultants in hospitals. They must then undertake regular refresher courses. Training is rightly an important part of the ambulance service, because lives are at stake. Because trusts have to fund their own training budgets, training inevitably becomes squeezed. I have received complaints that ambulance staff have had problems being accepted on paramedic courses.

Ambulance services provide additional facilities. Because of its rural nature, Staffordshire, particularly my constituency of Moorlands, developed the first responder scheme. Trained volunteers are on call to provide initial support and assurance to people within their own communities before the ambulance arrives. That can be vital in isolated rural areas, especially in the winter when it can be extremely difficult to reach houses and farms. Such services must rely on the generosity of local vehicle dealers to provide suitable transport. Since 1991, Staffordshire has had an air ambulance service, which can ensure that patients arrive at the north Staffordshire trauma centre quickly enough to have a real chance of survival and a speedy recovery. However, that service is having to raise £120,000 just to build a new helipad outside the accident and emergency department. For it to operate, it needs sponsorship on a daily basis. As we enter the 21st century, is that the right way forward for a modern ambulance service? I think not. I should be grateful to receive my hon. Friend's response.

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12.17 pm

The Parliamentary Under-Secretary of State for Health (Ms Gisela Stuart) : I congratulate my hon. Friend the Member for Stoke-on-Trent, North (Ms Walley) on securing the debate today, not least because she has had a longstanding interest in the performance of her local ambulance trust. I understand that she met my predecessor in 1998 together with the chief executive of the trust. She raised several issues, as did my hon. Friend the Member for Staffordshire, Moorlands (Charlotte Atkins), referring to the "Panorama" programme, the training of staff and regional variations. Lessons are being learned from what is happening in Staffordshire. I shall come on to core prioritisation and explain how it will not create a two-tier system, but allow us to prioritise. I agreed some time ago to visit my hon. Friend's constituency in Staffordshire and I shall be delighted to see what is happening there for myself.

Today's debate is very appropriate, because the ambulance service is at the cutting edge of the patients' experience in what are often life-threatening circumstances. The Government's commitment to a fair, fast and efficient service will be tested to its limits. We must consider what is happening to ambulance services in the context of the whole modernisation programme, which also covers NHS Direct and what is being done in accident and emergency departments to enable patients to receive a seamless service.

Training standards are important. The public expect a prompt response by skilled assistants when they call an ambulance in emergencies or life-threatening situations. That applies whether the response is from a conventional two-man ambulance or a lone paramedic in a fast-response vehicle.

It is also important to recognise that for some patients, particularly in cases of coronary heart disease or a stroke, the clinically based eight-minute recommended response time--Staffordshire is currently the only trust that meets the target--is extremely significant for recovery and long-term prospects. For that reason, we are keen to encourage every ambulance trust in the country to examine its practices. Such systems as Staffordshire's first responder scheme are also particularly helpful in rural areas.

I spent last Friday in an ambulance because I thought that I should know what I am talking about. That experience brought home to me how challenging the eight-minute response is. However, it is not just about making a rapid initial response; we also need trained control room staff and facilities so that vital advice can be given to the crew as they deal with the patient from arrival and during the journey to hospital. The evidence on what should and should not be done in the pre-hospital phase of an emergency is significantly lacking. That is a major obstacle that must be recognised. However, we have put into place clinical audits and research to devise the best model for the patient.

The Government modernisation agenda is based on improving our standards and service delivery on the basis of clinical evidence. That is also our approach to the ambulance service.

Ms Walley : As we are about to start the next round of the comprehensive spending review and the modernisation programme for the NHS is such an

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important part of that, does my hon. Friend agree that we should press the Chancellor to ensure that ambulances feature significantly in the NHS modernisation programme, with ring-fenced money to enable them to play their part in the integrated whole of the NHS that we know and love?

Ms Stuart : We all know that the comprehensive spending review and manager negotiations are complicated and tricky, but I assure my hon. Friend that, as part of my ministerial responsiblity, I will fight my corner as best I can.

Having looked at the general concepts, I turn to the example of Staffordshire. Ministers have frequently been accused of ignoring Staffordshire. That is far from the case. Not only is research being conducted by Sheffield to consider Staffordshire in its regular visits, but some of the lessons that we have learnt from Staffordshire are already being implemented. However, it is important that we have a clear picture of why things work in Staffordshire and, more to the point, of what can be transferred. I was interested to read this morning's parliamentary briefing from the NHS Confederation, which largely welcomes what we are doing. It states:


My hon. Friend the Member for Stoke-on-Trent, North mentioned targets. The current target is to respond to 75 per cent. of category A--immediately life-threatening--calls within eight minutes. Staffordshire has shown significant improvement in its handling of such cases, which has resulted in improved patient outcomes. Some of Staffordshire's radical and innovative measures have benefited the local population. That should be recognised.

Staffordshire and others are implementing more efficient services in several areas. One is improved dynamic location practices. I am sure that many of us have sometimes seen an ambulance waiting in a lay-by and wondered what it is doing. It is there deliberately--as part of a system of predicting demand patterns. Extremely successful statistical models are in use, so in Staffordshire ambulances stand by at the best locations in relation to expected demand patterns. Something similar is the case for improved relief levels. Having staff on call so that they can be brought in to meet unexpected peaks in demand has been effective, but is extremely demanding on the staff. There is a danger that they feel that they are on call for 24 hours.

Much the same applies to improved activation times, which require better control room procedures, preparation of crews and ambulance availability. All that cuts vital seconds in those essential fast response times. There must also be improvements in the matching of resources to demand, which means flexible rostering to ensure that the shifts match expected demand levels. It is only sensible to use the staff available most efficiently.

My hon. Friend the Member for Stoke-on-Trent, North fears that core prioritisation may lead to a two-tier system. We must recognise the great variation in the

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kind of calls that ambulance crews receive in a day. Any system must ensure that the most urgent calls--those when response is clearly critical within eight minutes--receive the first priority. Some calls--those in category C, for example--allow huge scope for NHS Direct to use a second stage of triaging to assess appropriate response levels. I assure my hon. Friend that core prioritisation is not a means by which we intend to create a two-tier system, but simply a means to ensure that the response is appropriate to the need.

We shall have the report on the research in Staffordshire by the end of the month, and it is important that we learn from it. I would like to make a couple of brief remarks about state registration and training. My hon. Friend wanted to know about the board, which I understand met for the first time yesterday. We are delighted that is up and running. My hon. Friend the Member for Staffordshire, Moorlands is right to believe that "Panorama" misrepresented the amount of training involved. Comparisons have been made with America, but gunshots and stabbings, which are common critical injuries in that country, require different kinds of response.

I would like to ensure that we all leave the debate with a recognition that ambulance facilities are part of our emergency service. The development of NHS Direct, ambulance facilities and accident and emergency facilities will provide important services. The failure of the vast majority of ambulance trusts to meet some response targets requires us to consider closely how we deliver the service. A patient needs a speedy response from the right people and to be taken to the right hospital at the right time. Staffordshire is giving us a good lead on how we should develop that.

Similarly, we will ensure that patient care is improved by considering how staff are used while the patient is in transit. We shall introduce state registration for paramedics and ensure that the people who respond to calls are appropriately trained and continue to be trained. We should also recognise what a difficult job those in the ambulance services have--a job in which demand is continually increasing. They make life-and-death decisions 24 hours a day, 365 days a year and have had responded to around 3 million calls in the past year. However, there is no room for complacency. We must consider the needs of rural and urban areas, and above all ensure that we respond in time when clinical conditions are the relevant indicators, especially for an eight-minute response time.


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