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7 Feb 2001 : Column 254WH

Ambulance Service (London)

11 am

Dr. Jenny Tonge (Richmond Park): Thank you, Madam Deputy Speaker. Is that how I am supposed to address you?

Mrs. Ray Michie (in the Chair) : Hon. Members are supposed to address me by name. I know that you can pronounce my name, Dr. Tonge, so perhaps you should do so.

Dr. Tonge : Thank you, Mrs. Michie. May I ask you to sort the confusion out with the Speaker's Office? Depending on who is in the Chair, we are sometimes expected to use names and sometimes titles. All Members share my confusion.

I should like to welcome two ambulance men to the Strangers Gallery. They are on their day off.

Mrs. Ray Michie (in the Chair) : The hon. Lady is not supposed to refer to people who are not in the Chamber.

Dr. Tonge : I am terribly sorry, Mrs. Michie.

All Members should have an interest in our debate, because the London ambulance service will come to pick us up when we have our heart attacks and strokes, which is not unusual in the House of Commons--although I hope that it does not happen too often. Perhaps the men more so than the women ought to declare an interest, because women are much fitter. Nevertheless, we all have an interest in the service, which is crucial to the life of Londoners. In Paris, the ambulance service headquarters has a special phone for the Assemble acute;e Nationale. I am glad to say that our ambulance service does not have any such phone, and that we take our chance with the rest of our constituents.

What a chance it is. If someone has a heart attack in a London street, there is a 1.8 per cent. chance that he will be alive a year later. In Paris, that person would have an 18 per cent. chance and, in America, he would have about a 30 per cent. chance. That is a poor figure for the United Kingdom. I know that that is due to a lack of cardio-pulmonary resuscitation techniques among the public, but it is also due to the great difficulty that the ambulance service has in meeting its response times. Its target is that 55 per cent. of all calls should be responded to within eight minutes, but it achieves only 34 per cent.

That is no fault of the people working in the service. As we all know, traffic congestion in London is currently impossible. I am told that the average speed of traffic is 10 mph.

Mr. Philip Hammond (Runnymede and Weybridge): Whose target is that 55 per cent? Is it in the patients charter? Is it an internal target or the purchaser's target?

Dr. Tonge : I think that it is the target in the patients charter, but I shall have to look into that.

It is a good day if the average speed of traffic in London is 10 mph. It regularly takes me much more than an hour to travel a little over five miles back to my constituency. Speed bumps and other traffic-calming

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measures have slowed traffic down, so they also slow ambulances down. Delays caused by congestion mean that the ambulance service needs more ambulances if it is to achieve a response time of eight minutes. An ambulance and crew has a range of only three miles, so more ambulances and more crews are needed to achieve those times.

The London ambulance service answers 700,000 calls a year with 350 ambulances. That is some service. Our lives may be in their hands, but those ambulance crews are still last in the league table of the nation's 32 ambulance trusts. The ambulance service was promised 25 more ambulances last year, but by December 2000 only 11 were staffed and operational. More ambulances are urgently needed. More paramedics on motor bikes are needed, because they can get through traffic to acutely ill people: they probably save lives while waiting for the ambulance crew to arrive. The London ambulance service improvement programme estimates that more than £11 million capital investment is needed, rather than the £5.5 million that it receives now.

Before I leave the subject of capital investment, I want to speak briefly about what most ambulance crews would call the icing on the cake--the helicopter. London, with a population of 6.5 million people, has one helicopter to use for really serious accidents. Paris has a population of 1.5 million people and has two helicopters. That is a shortfall for London. If I am ever taken acutely ill, I hope that it happens in France.

Other problems affect response times, and I touched on some of them in a debate on the health service in London a few weeks ago. The ambulance service is short of 400 ambulance crew. One reason for that is the maximum pay that staff can expect to receive. A qualified staff paramedic with many years' service can expect to earn about £20,000 a year including overtime. Those men and women put up drips, restart hearts that have stopped beating, make accurate assessments of the clinical condition of patients, stabilise broken backs and necks and crawl into the wreckage of road traffic accidents; and we reward them with a maximum payment of just under £20,000 a year.

In my pre-registration work as a junior hospital doctor, I relied on ambulance crews in emergencies, and I know many newly qualified doctors who feel the same as I do. We often rely on ambulance men and women in emergencies, yet we pay them only £20,000 a year. They cannot buy houses in London on that sort of money; nor can they give their families a decent life. It is no wonder that more than 10 per cent. of ambulance staff in London were lost during the past year to ambulance trusts in other parts of the country, where the living is easier, the housing is cheaper and they can just about manage on their pay. That movement of staff means that the training and dedication of those people are lost to the London ambulance service.

Of the £21 million given to the ambulance service nationwide last year to improve services, £2 million went to the London ambulance service and £19 million to services in the rest of the country, yet a third of all category A calls to the ambulance service are dealt with by the LAS. London does a third of the work, and receives a tenth of the funding. I rest my case.

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Another problem is the safety of staff. Ambulance staff in London suffer an average of one assault a day. It has got so bad that they are now being issued with safety vests. News Direct has sponsored a poster campaign in London to point out to the general public that those whose job it is to save lives in emergencies now have to risk their own lives to help others.

The constant misuse of the ambulance service by the public is another factor. A woman in my area splashed vinegar in her eye while making a salad dressing for a dinner party and called an ambulance. She dialled 999. Someone with a badly broken nail--extremely painful and extremely urgent!--dialled 999. All those calls cost the health service hundreds of pounds to deal with, but the patients charter states that the ambulance service must respond to all calls.

Some progress has been made in recent months. The London ambulance service has used some of its precious paramedics, who are supposed to be in ambulances answering emergency calls, to filter calls more effectively and to suggest to patients that they take the advice of a nurse or pharmacist, or ring NHS Direct. However, if the caller insists on having an ambulance--as people often do--the ambulance has to go and the money is wasted. We need some serious re-thinking about where ambulance stations are located and what their relationship is with NHS Direct and other NHS bases and emergency services. The ambulance service needs to be co-ordinated with the rest of the health service.

Savings, as well as improvements, can be made, especially if the LAS gets the computerised service that it desperately needs. Computers and the London ambulance service have a long history, and the service desperately needs a new system.

How much time is spent delivering the patient to hospital? It should take crews about 15 minutes to get from the door of the casualty department back to base. However, in winter, it can take more than 30 minutes. My hon. Friend the Member for Sutton and Cheam (Mr. Burstow) wants to comment on that in more depth. The problem is caused when accident and emergency departments are full and all the beds have been taken up. Sometimes the casualty department has no trolleys left, and the ambulance trolley has to suffice until one can be found and the patient can be transferred on to it. That is not a modern service.

We have expected far too much for far too long from the men and women of our ambulance service in London. It must be given special consideration. It needs support and a unified commissioning structure. It is ridiculous that it is commissioned by 16 different health authorities. Each of those health authorities has its own priorities. Acute hospital trusts are in deficit and other Government priority areas, which also deserve attention, have to be addressed by the trusts. The ambulance service always comes down the bottom of the list of priorities. If any of us in the Chamber has a coronary or a stroke, we will need the ambulance service pretty damn quick. It will not be good enough if it is at the bottom of the health authority's list of priorities.

Everyone accepts that there have been mistakes and mismanagement in the past in the London ambulance service. However, it now has an excellent chairman, who was appointed by the Government. The chief executive, who was appointed last year, is hugely popular with the

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staff. Having worked in the health service for over 30 years, I find it unusual that every ambulance man or woman I speak to thinks that their chief executive is a great guy, is working for the service and communicates with them. He makes a point of donning a reflector jacket and going out with an ambulance crew at least once every couple of weeks to ensure that he knows what is happening on the ground. Peter Bradley is a good chief executive and he should be encouraged. We probably have the best union-management relationship of all time in the London ambulance service.

In short, we have the chance of a lifetime radically to modernise and improve the service. I know that the Government care about the NHS. They should not forget the core of the NHS in London--the ambulances.

11.14 am

Mr. John Horam (Orpington): Mrs. Michie--I hope that that is correct.

Mrs. Ray Michie (in the Chair) : That will do very well.

Mr. Horam : I want to speak briefly, Mrs. Michie, because as a Minister in the previous Government I was privileged to have responsibility for all the ambulance services in the country, including London, from 1994 to 1997. As all hon. Members present probably know, owing to the historic problems of the London ambulance service, I shared responsibility for it with the Secretary of State.

As the hon. Member for Richmond Park (Dr. Tonge) pointed out, there have for a long time been problems in the London ambulance service that need special attention. As Minister responsible, I found that the difficulty was not that the service did not receive the special attention that it deserved by virtue of such factors as the size of London and congestion, but that it did not receive even ordinary attention. It was often the Cinderella of the services, which is astonishing given the fact that however good a hospital service may be, it is pointless to provide it if people fail to arrive there. I felt that my effort should be directed at obtaining for the service the attention that it needed.

Although I should not refer to some of my former special advisers, I am glad to note that they are taking an interest in the debate and pleased that they are still involved. They are from other services, but give their time to the London ambulance service. They were invaluable to me as a source of advice and I think that we made progress.

The problem in the past three years has been, first, a failure of management. For example, a tier of middle management was removed, leaving ordinary ambulance men with little in the way of hierarchy to which to report. The result has been, to an extent, what one might call canteen culture at its worst, which can create difficulties in the efficient running of an ambulance service. Ordinary ambulance men are superb people trying to do a job that is very difficult compared with, for example, that of the fire service. They have to do more with fewer resources and have a more relentless daily task and, in many respects, less public support. Certainly they have less Government support, and that remains the case.

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I was alarmed to note that the ambulance service is not mentioned in the NHS plan, which was produced in summer. That is astonishing. The centrality of the task of getting a sick person to hospital is not mentioned in the plan that is supposed to solve all problems. I was disappointed about that, because the mindset that I struggled against--that of the ambulance service as a kind of tail-end Charlie that would receive some small funds when they were available--is still in the Department. I worry about that.

The failure in the first instance has been one of management, which is why I am pleased about the appointment of a new chairman. The hon. Member for Richmond Park was right to mention the new chief executive, whom I, too, have found to be extremely popular with ambulance men in Bromley. That bodes well. Recruitment, and the use of ordinary ambulance men and women, have also proved difficult. For example, although we live in a 24-hour society in which problems evidently arise on Friday and Saturday nights, there is no overtime pay for weekends. Not to provide incentives to people to be available at those times of high demand is ludicrous, but that is the consequence of negotiations conducted without the common sense that one would expect. The trail of difficulties involving management and past negotiations has led to the current problems. One would hope that an ambulance would be waiting to deal with any emergency that might arise, but the reverse is nearer the truth and, if an accident happens, it is to be hoped that an ambulance will arrive.

As the hon. Member for Richmond Park said, the figure for meeting the eight-minute deadline has fallen to 32 per cent. I had thought that it was 36 per cent., but whatever it is, it is far below the necessary level. It is also far below that level in provincial cities. London has special problems, which mean that one should have lower expectations for the timing of ambulance arrivals. Although the expectations that one would have in provincial cities simply could not be met, the figures should be much better. Otherwise, we would not be providing a proper service. Indeed, to some extent, no ambulance service operates at weekends.

Mr. Hammond : I want to probe my hon. Friend's statement that it would not be reasonable to expect the London ambulance service to meet the response times that are met in provincial cities. I understand that the London ambulance service's percentage response time achievement in central London is not bad, but that in outer London the response time gets worse, dragging down the overall average. Is not that his understanding?

Mr. Horam : I am not familiar with the distinction between inner and outer London on response times. I was referring to the fact that Newcastle and Liverpool have much better ambulance response times than London. London has always been way behind the response times in cities throughout the rest of the country, and I think that the Minister would agree with that. That is certainly my experience.

London has particular problems such as the size of the city and the historic problems of the service. For example, the lack of computerisation is still a problem. Everything works by paper after all these years, although several efforts have been made to install a fully computerised system, which is standard in cities such as

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Liverpool and Newcastle, which are way ahead. Such problems must be solved. I am appalled to find that, four years after I handed over responsibility, the London system is, amazingly, still paper based. Progress has been extremely slow, and the results are unsatisfactory to Londoners and to ordinary ambulance men. They want proper support and a proper system of which they can be proud, but they have neither.

The Parliamentary Under-Secretary of State for Health (Ms Gisela Stuart) : The hon. Gentleman speaks with considerable experience, but does he agree that the disastrous attempt to introduce an information technology system to the London ambulance service in the 1990s knocked the service back considerably? The events surrounding that prevented it from making progress in that area as quickly as others did. Will he comment on that?

Mr. Horam : Yes, there were all sorts of reasons for that, many of which were related to the traditional set-up and relations between the trade unions and the management. No one would defend that now. It is poor that we have made so little progress, even in 2001, compared with that made in provincial cities, which were computerised in my time. London still is not and that is the problem. I hope that the Minister will say something positive about that, because progress must be made on that front.

I am pleased that the service has a new chairman--who, incidentally, is a resident of my own borough, Bromley. I have spoken to him, and he is very effective. The service also has a new chief executive. The management, at the instigation of a new chairman and chief executive, are much more understanding and friendly towards their staff and they are making a genuine effort to understand the problems that staff face in delivering a decent service. The impression that I have gained from the people to whom I have spoken at the ambulance headquarters in Bromley is that management are very staff oriented. They are grasping the nettle, realising that they have to work with staff, try to recruit staff and understand their problems.

The management must carefully consider pay and recruitment, which are fundamental problems. As the hon. Member for Richmond Park said, given the competition in the job market and housing problems in the London area, the organisation will not work if those with considerable experience are paid a salary of £19,000 or £20,000. One cannot have a decent service and have the right quality and quantity of people if that situation is not addressed fundamentally. The management well understand that, and are doing their best to do something about it.

Management are now much more flexible and coherent and I understand that they have a clear idea about capital and resource requirements and about the fact that the service needs some £12 million next year to contribute to providing more and better ambulances, better equipment and facilities. The management have set out a clear programme for the next four or five years, which the Government have been given. I hope that the new team can build on the undoubted good will that is being generated among staff and address the problems.

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I hope, too, that the Government will chip in with the right sort of funding and no longer treat the service as a Cinderella and that London will once again be proud of its ambulance service.

11.25 am

Mr. Simon Hughes (Southwark, North and Bermondsey): It is a privilege to serve under you, Mrs. Michie, as I do not think that I have done so before. If I may say so without embarrassing you, although I am not your constituent, I am one of your biggest fans and only regret that you will not be here in the next Parliament, as some of us hope to be.

I am glad that we are having the debate because it is important for London. That shows how magnanimous I am, because I have been applying for weeks for the same debate and my hon. Friend the Member for Richmond Park (Dr. Tonge) beat me to it. Last year, six Liberal Democrat Members decided that we must raise the issue and we have all done so in different ways. There was nothing conspiratorial about that--we all agreed that the matter was important and my three colleagues who cannot be present are very much associated with the issue. We benefited collectively from having been briefed and brought up to date before Christmas by the new chief executive, to whom tribute has been paid.

Some two weeks before Christmas, at about 9 o'clock one evening, I went to the headquarters of the London ambulance service in Waterloo road, which lies outside my constituency by about two yards. I went out with a crew of two ambulance drivers, Bart Wood and Peter Gallen, on their evening shift in a conventional London ambulance. Within a minute or two, they received a call to attend to a young boy, living in Walworth, who was choking and at severe risk of heart failure. They drove through the traffic--not easy, even at that time of night--through narrow streets on which the parking made access almost impossible. They made it to the house and were joined by their colleague, Ian Price, who was on a motor cycle. Paramedics with ambulance crews often use such vehicles nowadays. As far as I could see, when the crew took that youngster and his parents to St. Thomas's, they saved his life. In lay terms, it prevented that child from dying that evening. That was a dramatic introduction to an evening shift.

Last month, Jim and Christine Bradford, my constituents, had a tragic experience. Michael Bradford, their 14-year-old son, was knocked down in St. James road in Bermondsey when he ran out between two cars. He died after a week in the London hospital. He was the only child of those parents--one had two daughters by a previous marriage. I went to see Jim and Christine the day before the funeral and spent time with them at their home before going to the memorial service at the school and the funeral service. In their grief and desolation, they paid tribute to the air ambulance service that had taken Michael from the road accident over the river to the London hospital.

Although Michael did not survive, his parents could not have paid higher tribute to that service. They could not understand why, in the whole of London, there is only one air ambulance--that point was made by my hon. Friend the Member for Richmond Park. Unless things have changed since I made my visit as health spokesman for our party, that air ambulance, I

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understand, is largely funded by private money, not the NHS. Those are two recent examples, which took place within a month of each other, of the work of the ambulance services, the air rescue service and the support services in trying to save lives in London.

I join in the tributes paid by my hon. Friend the Member for Richmond Park and the hon. Member for Orpington (Mr. Horam) to a service that has had terrible difficulties, but also has the resolution and will to overcome them. It is asking political representatives, in particular the Government, for help to change from a service that is overstretched and unable to meet its target times, and sometimes unable to do the job that it wants to do and save the lives that it can, to the Rolls-Royce service that we would expect in a capital city such as ours.

I want to concentrate on pay, but, by way of solidarity with colleagues, shall flag up the other points that have been mentioned. First, it is clearly sensible that we change as quickly as possible from a paper-based system, which is not sufficiently reliable or logical, to a computer-based, automatic, electronic system. I know the history and remember all that difficulty with the old computer that crashed--the whole system went to pieces and the IT did not work. The Minister referred to that. That is history; we need to introduce a system that allows information received at the call centre to be passed on for the crew to be summoned, and the sooner we can have that, the better.

Secondly, we need the kit to do the job. We need the ambulances on the ground to be able to respond. My hon. Friend the Member for Richmond Park referred to the fact that there is a bid in for and a promise of 25 more fast response ambulances, but only 11 have been on the road. Again, I talked to the crew who were with me that day, and who have been kind enough to come to Westminster this morning, and they said that even on one of their most recent days on duty they were scrabbling around for an oxygen cylinder, because there was not one in the ambulance. Some ambulances have all the kit on board; some do not because it is not there to be had. That does not allow crews to do their job properly.

The third issue concerns staff. This may sound sycophantic, and I do not mean it to, but I knew that I would be impressed by the professionalism of the crew. I expected that, just as I did when I visited the fire service and the police. I expect a professional job to be done and that is invariably the case, probably for 99.9 per cent. of the time. I was more impressed than I ever imagined by not just their professionalism, but their knowledge, expertise, competence and calmness--all the qualities that are vital to doing the job well. A better job could not have been done, and I say that in tribute to the individuals concerned.

I agree that it is unacceptable that no matter how many years' service people have done and no matter how much experience they have gained, their top-whack pay is about £20,000. It is unacceptable that there is no increment as a reward for service. People give five or 10 years' service, but have nothing to show for it. Why stay? Why stay in London? Why not move elsewhere, where there is less pressure? Why not move to a place where house prices, travel costs and the cost of living are lower? Why not move to an area where the incidence of

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severe accidents and injury is lower? Why not transfer to another profession? Why not go into the private sector? There is no incentive to stay.

We all think that an election is coming down the track. The Minister may not know formally any more than I do as to when it will be, but we are all on alert for the spring. We understand that there will be a Budget in March, and it may be meant as a backdrop to an election. The London ambulance service has bid for and needs about £30 million more than its budget. There must be a way for the Government, if they wanted to, so to adjust their comprehensive spending review plans that they could find that money. The kitty is full; public coffers are overflowing with resources; we have never had it so good in terms of what the Chancellor has to give out.

I make a plea now because we must hold on to public servants whom we value, and they need proper remuneration that is incremental through their career. As the hon. Member for Orpington rightly said, we should recognise that we need them most on Friday and Saturday nights, during anti-social hours when those people who have the choice would not work. We also need them on weekends, bank holidays, new year's eve and all those other occasions when people prefer not to work. We need about 500 extra people so that the job can be done without having to scramble to catch up.

I do not know how the Minister can deliver that extra money, but I know that Mr. Bradley, the respected chief executive, and Mr. Renton, who seems to be a good trust chairman, fully support the request. I am satisfied that the money will be well spent if it comes to the London ambulance service, because the regimes are in place to achieve that. Those who work for the service want to continue doing the job, but they also want their plea for proper remuneration to be heard so that they can continue to provide the excellent service that they are trained and willing to offer to residents and workers and those who visit our capital city.

I hope that the Government will make positive responses to my hon. Friend the Member for Richmond Park, the hon. Member for Orpington and other hon. Members. The service needs money on the table and a new pay regime this year--I mean this year--which will provide decent pay, and decent increments for service given, for some of the most professional people in the country.

11.36 am

Mr. Paul Burstow (Sutton and Cheam): I congratulate my hon. Friend the Member for Richmond Park (Dr. Tonge) on securing this debate. As my hon. Friend the Member for Southwark, North and Bermondsey (Mr. Hughes) said, various hon. Members have tried to secure this debate in Westminster Hall for some time. The London ambulance service warrants our attention and support for the work that it does. I congratulate the hon. Member for Orpington (Mr. Horam) on taking part in this debate. I want to respond to some of the points that he and my hon. Friends have made.

The public measure the London ambulance service by how quickly an ambulance turns up at their door after they have dialled 999, administers the necessary immediate treatment and takes them to an accident and emergency department or an intensive care unit to

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ensure that they continue to stay alive. The work of the ambulance service is a matter of life and death. It is about rapid response--the public are concerned about response times. It is also about a lot more than that, as I have become increasingly aware as a result of my discussions with the London ambulance service. However, we must consider the issue of response times.

The Government have rightly set new standards for category A life-threatening calls. They have set a national target of 90 per cent. of calls to be responded to within eight minutes. Achieving such a target or improving response times will result in more lives being saved. Given the sheer volume of 999 calls that are made--700,000 to 1 million calls a year, or 3,000 a day--600 more people would be saved a year in London alone if performance standards on response times were achieved. As my hon. Friend the Member for Richmond Park rightly said, only 34 per cent. of 999 calls in London are attended within eight minutes. From March of this year, the target set for the London ambulance service is 55 per cent. of category A calls to be attended within eight minutes. I am not certain whether that target can be met, but I know that the London ambulance service has made great strides and that attendance times have improved since the last time the relevant national statistics were published. We wait with interest to see what the performance indicators suggest has happened in the past year.

Several obstacles are in the way of achieving better response times. Staff recruitment and retention is a problem. Turnaround times in accident and emergency departments need to be explored in detail, and we must consider the vexed question of traffic in London and the fact that there is gridlock at certain times of the day in both inner and outer London, which makes it impossible for ambulance crews to get through. Earlier today, I discussed with an ambulance crew some of their worries, and they said that junctions are all too often the pinch points. A junction can provide ambulances with the way through the traffic, but because thought is not always given to the use of yellow box markings, everyone stays in the junction. What I experienced this morning when I drove to the House demonstrated that problem graphically. The traffic drew to a halt, and all the junctions locked up. I dread to think what it must be like to sit behind the wheel of an ambulance at such times, knowing that the clock is ticking past the five minutes in which to achieve the eight-minute response time, and to know that someone is relying on the ambulance to arrive.

Staff recruitment and retention are undoubtedly an important part of the problem. It is alarming that the turnover of staff in the London ambulance service is double that of any other urban ambulance service in the country. The turnover rate is about 10 per cent. Each month, 20 staff leave the London ambulance service. Some people may argue that a turnover rate of 10 per cent. is nothing to worry about, but given that this relatively small specialist work force work to full capacity, the service can ill afford such a staff turnover.

Something must be done about the turnover of staff as it imposes extra costs on the London ambulance service. In the financial year that is coming to an end, the costs of recruitment to fill the gaps caused by staff

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leaving the London ambulance service will be about £1.5 million. Included in that figure is the cost of placing advertisements that barely generate a response. Late last year, an advertising campaign throughout London drew in only 15 responses. At the same time, 20 more people went out the door to go elsewhere in the country. The £1.5 million that has been lost to the LAS could have been invested in the service, were it not for the serious staff retention problems in London.

As my hon. Friend the Member for Richmond Park said, we must take into account the high cost of living in London, which is not fully reflected in the salaries of ambulance crews. Indeed, they receive the lowest pay of all key public sector workers. The police receive about £19,730 per annum plus London allowances and qualified nurses receive £18,300 plus London allowances. Such levels of pay are not generous, but they are more than ambulance crews receive, so it is hardly surprising that people are leaving the service.

Ambulance crews have lower annual leave entitlements than nurses, firefighters or police officers, and they do not receive a shift or unsocial hours allowance. The Government put additional resources into ambulance services throughout the country. However, as my hon. Friend the Member for Richmond Park rightly identified, of the £21 million extra that was allocated, only £2 million went to London despite the fact that a third of all category A 999 calls are made in London. That was a misallocation of resources. It failed to meet the identifiable need to improve the service.

I am not criticising the fact that extra money was provided, but as a result ambulance services in the west country, Hertfordshire and elsewhere have been able to offer attractive packages--golden hellos--to attract ambulance crews to move out of London. They are attracting highly skilled paramedics to a better quality of life and a better pay package. It is no wonder that London is losing 20 staff a month from the ambulance service. As the hon. Member for Orpington rightly said, even the best A&E departments in the world could not do their job properly and could not make a difference to people's lives if patients could not be taken to them quickly enough.

Over 1,000 hours a month are lost because of delays at A&E departments. In January, the average wait for an ambulance crew at an A&E department was 24 minutes. That figure has progressively increased from January to January--24 minutes while an ambulance is waiting to be released to go back on duty to attend 999 calls. That reduces the resources available to respond to 999 calls. It is part of the systemic problem. We have had debates in this Chamber and on the Floor of the House about delayed discharge, which ultimately results in an ambulance being delayed in an A&E department. If a bed is blocked, or there is a delayed discharge in the hospital, the problem feeds back down to the A&E department--no beds are available, so people cannot be admitted to hospital, patients have to wait on trolleys because there are no beds, and those trolleys often come from the back of ambulances. As a result, people wait to move on.

One of the problems raised during a conversation with an ambulance crew was that of the time wasted at an A&E department, especially over booking-in arrangements, which took more than 10 minutes on average. Anything that can be done to shorten the time

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that ambulance crews are involved in that procedure would be welcomed. The national health service should look into that when considering the role of A&E departments in freeing up time.

Ms Stuart : How would the hon. Gentleman square that suggestion with what I have heard from ambulance crews who felt that it was important to have a good relationship with A&E departments? The real trick is to know when the service is so stretched that the ambulance crew should book in and go, but they felt that the time spent booking in was important in building a relationship. The time is not at issue; it is what happens in that time. The procedure should be streamlined, but the problem is not as simple as the hon. Gentleman implies.

Mr. Burstow : I agree that none of the measures are simple. What is required is the development of a relationship, as the Minister said, but also some clarity about the protocols used in the operation of the London ambulance service and A&E departments around London. It is not beyond the wit of the staff and the management to develop such relationships. The issue could and should be examined in any attempt to deal with the time taken by crews waiting outside A&E departments.

Mr. Hammond : In examining initiatives elsewhere in the country, is not part of the solution to the problem the use of in-vehicle computerisation, so that communication with the A&E department starts from the moment that the vehicle begins its return journey?

Mr. Burstow : The hon. Gentleman has helpfully brought me on to my next point, which is about capital investment in information technology and communications.

Mr. Simon Hughes : Will my hon. Friend give way before he goes on to talk about the capital investment programme?

Mr. Burstow : Yes, as we have the time.

Mr. Hughes : Having heard my hon. Friend's dialogue with the Minister, it would be most helpful if, in dealing with this practical issue, an urgent countrywide consultation could take place between ambulance crews and their representatives and NHS trust staff. We should also listen to the views of others who are not ambulance personnel, doctors or nurses. Lay civilian clerical staff could assist in A&E departments and deal with paperwork when there is no need for personal contact. It would be a helpful move forward if the Minister would give such an undertaking.

Mr. Burstow : All options should be explored. The Minister was listening carefully to what my hon. Friend had to say, and I hope that he and his officials will pick up on that point.

I want to return to the important point about capital and investment mentioned by the hon. Member for Runnymede and Weybridge (Mr. Hammond), but first I want to talk about traffic in London. Through our personal experience and other evidence, we all know

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that traffic in London is going slower and slower. As my hon. Friend the Member for Richmond Park mentioned, that has consequences for the operation of the London ambulance service. It is confined to ever smaller areas because of the distance it can travel in the eight-minute response time--the operating radius is now about three miles and is getting shorter. Thus, more and more ambulance crews and ambulances are needed to cover the whole of London within the response time that the public considers satisfactory. Given the change in traffic speeds between morning and evening peaks, just to maintain response time would require a 25 to 26 per cent. increase in the number of ambulances.

That brings me to the issue of capital investment in the ambulance service. The London ambulance service has a £5.7 million shortfall in its capital programme, which has already resulted in a change to the policy on the working life of ambulances from five to six years, and the capital programme of £5.5 million available under the external financing limit is eaten up just replacing ambulances. We have a serious problem in London, and the LAS needs to spend an extra £1.5 million in the coming year to purchase a further 10 ambulances and 23 rapid response units to enable it to achieve better response times. Whether the extra vehicles have the IT that the hon. Member for Runnymede and Weybridge wants or not, they are essential to improve response times.

The funding arrangements for the London ambulance service are unsatisfactory organisationally, let alone in the amount of money available. In London, 16 health authorities are responsible collectively for commissioning the London ambulance service, and I certainly hope that by 16 February they will have good news about their commissioning intentions and resources, but all of those health authorities have other pressures on them. They have responsibility for acute hospitals, who have advocates on their behalf; for primary care needs; and for the Government's national priorities on cancer and coronary heart conditions. The Government must seriously consider allowing the London ambulance service to be commissioned on a Londonwide basis--perhaps through the NHS region--so that someone has clear responsibility for thinking strategically about its commissioning. By fragmenting it across 16 health authorities, that vision is lost and there is no clear ownership of responsibility for commissioning services. That would do a great deal for the confidence of the London ambulance service.

The London ambulance service now has a clear improvement programme, and it is delivering results. It needs support and resources to carry that programme through. In particular, it needs flexibility to reward and retain staff, and we need action to deal with gridlock and the turnaround problems of accident and emergency departments.

London ambulance crews have been underpaid, overworked and overlooked for far too long. The London ambulance service needs a period of sustained investment. Its new management team is able to deliver, and it certainly has staff of a quality to deliver the service. I hope that, in partnership, the Government will be able to deliver as well.

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11.53 am

Mr. Harry Cohen (Leyton and Wanstead): I shall be brief.

Mrs. Ray Michie (in the Chair) : Yes. I hope to start the winding-up speeches at 12 o'clock.

Mr. Cohen : I shall not speak beyond that, Mrs. Michie. I pay tribute to the hon. Member for Richmond Park (Dr. Tonge) for introducing this important debate and apologise to her and, indeed, to you for being unable to be present for the start. I was at a Defence Committee meeting attended by the Secretary of State.

I visited the London ambulance service in January 2000. The previous chief executive left shortly afterwards, but that had nothing to do with my visit. I looked around and met the staff who operate the 999 service and run the ambulances. I was impressed by their work, so I am happy to echo the comment about pay being an important factor both for them and for ambulance staff. However, I noticed that there was no system for tracking ambulances. That surprised me, because only a couple of months earlier I visited a taxi firm called Computer Cab with a couple of other Members of Parliament. It had a tracking system, so staff knew where every taxi was. I have been arguing the case both to the London ambulance service and to Ministers that we should take advantage of the technology. That is my main reason for speaking in the debate.

The new chief executive of the London ambulance service, Peter Bradley, wrote to me in November. His letter stated:

I shall make a couple more brief points. The first concerns cardiac care, which is important and needs investment. There is a programme, which is part of the London ambulance service's plans to improve cardiac care, to replace the old-fashioned type of defibrillation units with AEDs--automatic external defibrillators.

The survival rate a year after people have been taken to hospital with a coronary by the London ambulance service is less than 2 per cent. Although that figure is comparable to that for most other major urban conurbations, it is still poor. I see from the London ambulance service plans that it would prefer that figure to be much closer to 15 per cent. Obviously, that would require investment, but the London ambulance service thinks that it is achievable, so an effort should be made. The modernisation of defibrillators is part of that process. There is also a need to upgrade clot busters so that ambulance paramedics can deliver the injection and answers to my parliamentary questions suggest that progress is being made on that important way in which paramedics could increase the cardiac care survival rate.

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My final point concerns the London ambulance service management plan. In his letter to me, Mr. Bradley said that:

Mr. Bradley says that he has discussed the investment programme with the Government. I hope that the Minister will tell us that the £6 million investment is the first step in delivering the management programme that Londoners need if many lives are to be saved.

11.59 am

Mr. Philip Hammond (Runnymede and Weybridge): I congratulate the hon. Member for Richmond Park (Dr. Tonge) on achieving this debate and on the commendable brevity of her opening speech. Too many of these debates in Westminster Hall run out of time because the opening speaker takes 45 or 50 minutes to make his or her contribution.

Having listened to the debate so far, it seems that virtually every Member of Parliament has visited the London ambulance service in Waterloo. I have certainly added to their burden, and I wonder how much better the service might be if staff did not have to spend time showing MPs around the control room. The fact is that despite the dedicated efforts of the thousands of men and women in the London ambulance service, it is failing to deliver an acceptable service to Londoners. It is bottom of all the league tables.

The hon. Member for Richmond Park quoted a target figure of 55 per cent. for an eight-minute response time to category A calls. I should like to probe the Minister about who set that target. My understanding is that the patients charter target was that, by April 2001, 75 per cent. of category A calls would be answered within eight minutes. The 55 per cent. figure represents the purchasers' target--the service for which they have been willing to pay in a negotiated settlement with London ambulance service. If I am not mistaken, there is a 75 per cent. national target, but health authorities in London have decided that they will only pay for a service that delivers a 55 per cent. target. If that is correct, will the Minister tell us why people in London should be prepared to pay--sometimes with their lives, as shown by the figures quoted by the hon. Member for Sutton and Cheam (Mr. Burstow)--for the lower level of planned service that the London purchasers are willing to finance?

Mr. Burstow : The hon. Gentleman may be interested to know that the London ambulance service's own targets are 65 per cent. by spring 2002 and 75 per cent. by March 2003. As the hon. Gentleman said, there is a caveat: money must be available.

Mr. Hammond : I look forward to hearing what the Minister has to say about that. Will she also tell us whether, under the Londonwide purchasing arrangements, the same service targets are in operation thoughout London, because the achievement rates have been different? In central London, the London

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ambulance service has been achieving about 60 per cent. category A eight-minute responses, which is good by any standards across the country. In other areas--I am afraid that it is the usual suspects, such as Newham, where service provision is repeatedly less good--the response times are higher.

Given the overall London percentage achievements, 60 per cent. in central London shows how poor the response times must be in outer London. Although, as the hon. Member for Richmond Park said, we do not have a hotline to the London ambulance service from this place, we are privileged to be in an area that is better served than some of our neighbours across London. Will the Minister tell us whether it is acceptable in her view that London ambulance service purchasers should be allowed, by design, to purchase a lower standard of service response than that set by the Government's own targets?

Will the Minister also explain the distinction between categories A and B? Of course the focus is on category A response times for immediately life-threatening incidents. The last time I called the London ambulance service, I was with an elderly person who had fallen over and broken a leg and was not able to move. That is not a life-threatening condition, but it is not a pleasant position to be in at 11.30 on a Friday night in a street in the constituency of the hon. Member for Southwark, North and Bermondsey (Mr. Hughes). We all know that Friday nights are a busy time for the ambulance service, but I think that the Minister would agree that to have to wait for 45 or 50 minutes is unacceptable.

The Government must make a clear statement about the targets that they expect the London ambulance service and its purchasers to achieve for the people of London, so that we can measure what purchasers and providers are agreeing against the targets that the Government, as the responsible body, are setting.

Will the Minister give us her assessment of the extent to which capital deficiency and inadequacy of capital spending programmes is at the heart of the problem and the extent to which it is a problem of staff retention and recruitment? In the latter context, what are the Government doing to deal with the problems of providing public services in the south-east?

Can the Minister tell us whether she is satisfied that commissioning arrangements, which the hon. Member for Sutton and Cheam described as fragmented, are not a contributory factor to the relatively poor level of service delivery? Specifically, how do the Government allocate additional cash resources that are made available for ambulance services? We have already heard that of the £21 million that was made available last year, only 10 per cent. was allocated to London, although London faces a third of all category A calls in the country.

What lessons have the Minister and her Department drawn from comparisons between organisational systems and service achievement in the London ambulance service and the ambulance services of other cities? I am sure that she will mention computerisation and the use of technology. When I went to the London ambulance control centre, I was quite shocked to find little pieces of card being physically moved about the room. Although there were plenty of computer screens, the system appeared to be essentially paper-dependent,

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not computer-dependent. Perhaps the Minister can tell us that matters have moved on in the past 12 months. Will she say how far the Government are willing to support the extension of technology?

The hon. Member for Leyton and Wanstead (Mr. Cohen) talked about the situation in which heart attack victims find themselves. In Paris about 10 years ago, I saw a demonstration of how paramedics are able to transmit an ECG reading from the scene of an incident back to consultants in a hospital, who make a diagnosis and instruct the paramedics at the scene on the administration of drugs. That is the kind of initiative that we should be considering. It is rather sad that it took place 10 years ago in Paris, yet we still have nothing comparable in this country. Will the Minister tell us whether the Government are willing to consider such an initiative? I imagine that it would require changes in legislation dealing with who can administer what treatment.

Will the Minister consider the publication of more information about response times to category A calls? We know the percentage that are within eight minutes, but it is important to know whether the remainder of the calls are responded to in nine or 90 minutes. If 39 per cent. are responded to in eight minutes and 75 per cent. in 10 minutes, that would be a different order of problem to the remainder being very much delayed.

Will the Minister tell us about international comparative figures? How does London stand in the league table of ambulance response times in comparable cities? What is the Government's assessment of the impact that misuse of the ambulance service has on the service delivery equation in London? The hon. Member for Sutton and Cheam talked about the waste of ambulance time when ambulances are stacked up at A&E departments as the problems of those departments multiply. That does not happen only because they are waiting to unload. I have also heard graphic descriptions of ambulance crews caring for patients because no one else is available to do so. Until they are able to hand over care of the patient, they cannot leave the A&E department. However, it would be an equal waste of time for ambulances to respond to calls that should not have been made, or which did not warrant an ambulance response. I should be grateful if the Minister would clarify the Government's view on that issue and what they intend to do about it.

We all recognise the phenomenal escalation of demand that the London ambulance service faces, and the special problems associated with London's traffic. We know about the difficulties in recruiting and retaining public service personnel in London and the south-east. The London ambulance service is an essential service that provides support for people who live and work in London, and for the many millions who visit the city. However, in overall terms it is not delivering an adequate service to Londoners. Worse than that, poor overall performance figures conceal pockets of far worse performance in certain areas.

We recognise the scale of the problems, but we must respond not by cutting targets to an unacceptable level, but by addressing the problems head on. If the percentage improvement in London ambulance response times that was achieved between 1994 and 1997 had been achieved between 1997 and now, 100 per cent. of category A calls would have been responded to within

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eight minutes. It is the Government's duty to ensure that the London ambulance service delivers an acceptable service to Londoners, and I look forward to the Minister's response to the many specific points that were put to her this morning.

12.11 pm

The Parliamentary Under-Secretary of State for Health (Ms Gisela Stuart) : I congratulate the hon. Member for Richmond Park (Dr. Tonge) on securing this debate, and I shall try to deal with many of the questions that were asked during the debate. I am sure that the hon. Member for Runnymede and Weybridge (Mr. Hammond) will forgive me for beginning by discussing the points raised by the hon. Lady who initiated the debate. I shall work my way through the points in a sequence that will sometimes appear logical, and sometimes not.

The hon. Member for Richmond Park said that we should not forget the ambulance services, and I should make it clear that in the past few years we have far from forgotten them. The hon. Member for Orpington (Mr. Horam) expressed his disappointment at the apparent lack of specific reference to ambulance services in the NHS plan. Ambulances have for too long been viewed in isolation. Their function is much wider than that of a simple people carrier from point A to point B. Ambulance staff are highly trained professionals who have a very important function to fulfil. The NHS plan refers to telemedicine, cardiac work and the provision of thrombolysis by paramedics. Ambulance services must be a far more integrated part of the jigsaw of emergency medicine, and they are very much in our minds. Indeed, the Secretary of State has commissioned a review of emergency care and out-of-hours services, which are intrinsically linked.

Given the number of people who visit the London ambulance service--I, too, have visited it on a number of occasions--I am tempted to suggest that it should charge for visits. I have also visited my own West Midlands ambulance service, which kindly allowed me to spend a day with its staff. It was an extraordinary learning experience, because the various problems to which hon. Members have referred came to the forefront.

Reference was made to helicopter air ambulances, and I shall refer to them specifically, but I want first to make a general point. In London, the helicopter emergency medical service is an important component of the ambulance service, but I want to correct two misconceptions. First, helicopters are not the universal panacea that they are sometimes thought to be. They cannot fly at night, so they cannot operate for between eight and 12 hours of the day. Secondly, in many areas public funds contribute to the service, but we must not underestimate the amount of NHS money that is provided. In London, a large proportion of the cost of running the service--some £1.4 million a year--is funded by the NHS. NHS funding pays for maintenance of the helicopters, fuel, insurance and all costs associated with the pilots, operations staff and paramedics. On top of that, only 84 hospitals in the country and about 12 in London have helipads. I do not underestimate the role of helicopters, but they are not the panacea that is sometimes suggested.

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The hon. Member for Orpington suggested that the whole system should be reviewed, but I hope that he acknowledges the considerable progress that has been made. There was a danger during our debate of giving the impression that all was doom and gloom. The London ambulance service has always faced a difficult task and it has made huge improvements.

Mr. Hammond : Does the Minister acknowldge that concern is being expressed because the rate of improvement seems to have slowed down dramatically? Between 1993-94 and 1996-97, the percentage of eight-minute responses to category A calls tripled from 12 per cent. to 35 per cent., but between 1996-97 and 1998-99, it improved from 35 per cent. to only 39 per cent. It seems that the rate of progress is slowing down.

Ms Stuart : I shall examine those figures, because it is easy to extrapolate figures and draw conclusions. I want to speak about the improvements that have been made.

My hon. Friend the Member for Leyton and Wanstead (Mr. Cohen) referred to a tracking system. I saw such a system in operation when I visited Merseyside ambulance service. The development of such a system is being looked into, and I shall come back to my hon. Friend with more precise information about the time scale.

The hon. Members for Sutton and Cheam (Mr. Burstow) and for Southwark, North and Bermondsey (Mr. Hughes) made some valuable points, but they always think that everything will be resolved with money. The hon. Member for Runnymede and Weybridge (Mr. Hammond) referred to the 55 per cent. target in London and whether we can meet it. Of the money allocated, £21 million was to help towards the improvement of targets.

It is important to pay tribute to the London ambulance service on the improvements that have been made following various initiatives. Its legitimate and correct aspiration is to provide the city with the ambulance service that it deserves. It handles around 20 per cent. of the total ambulance work load in England. The population of 7 million in London increases each day because of the 3 million visitors to the city. The London ambulance service has more than 3,000 staff and 600 vehicles and last year handled around 12 million calls. Dealing with that volume of calls is not easy, and I want to thank members of the London ambulance service for their tremendous work day in, day out. The value of that work is abundantly clear from the way in which they dealt with crises such as the Paddington train crash and the Brixton and Soho bombings. Given that the service receives about 3,000 calls a day, it is vital that the LAS is considered an integral part of the NHS.

Before dealing with the situation in London, I shall refer to ambulance services across the country. The Government's priority is to save more lives by providing faster and more responsive emergency ambulance services. Clinical evidence shows that early defibrillation and resuscitation saves more lives. The Government set challenging response targets for all ambulance services as soon as we came into office in 1997. Since then, ambulance services have improved their response times through a range of measures, including more staff and vehicles, faster activation, better matching of resources

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to demand, dynamic as opposed to station-based cover, effective relief levels and rotas, and flexible responses to 999 calls.

I shall compare two ambulance services that appear to have had real difficulties in meeting the 75 per cent. target. One is in an urban area; the other is in a rural area. The method of meeting those targets varies from one area to another.

Dr. Tonge : That is all very interesting, but the Minister is being far too general in her response. I asked a number of questions about the London ambulance service, not least about the level of pay. Only nine minutes of this debate are left; shall we be given any answers?

Ms Stuart : I hope to proceed. I need to put those matters into the overall context.

Mr. Simon Hughes : Can we have the answers?

Ms Stuart : Would the hon. Gentleman do me the courtesy of listening to my response?

We are also introducing a range of community and volunteer responder schemes; it is no answer simply to say that we need more ambulances. Those new schemes will include the use of motor cycles and rapid response vehicles that can make their way through traffic congestion more easily. Mention was made of traffic problems, but even such things as the signposting of streets and the numbering of houses can make a difference. We spoke also of traffic entering marked spaces on roads that can cause junctions to become blocked. We are not dealing with aspects of the problem in isolation. I urge hon. Members to consider the matter in the round.

Liberal Democrat Members in particular wanted the Government to make another commitment to giving extra money to the London ambulance service. We were told that that was the only solution. Perhaps they have a little list; but those extra demands add up. Every time we have a debate with Liberal Democrat Members, they demand more money.

Mr. Hammond : Will the hon. Lady give way?

Ms Stuart : No, I must make progress.

The problem is not simply one of extra ambulances. I have already said that ambulance service response times have improved significantly since we came to office. We expect ambulance trusts to achieve that target by 31 March--

Mr. Hammond : What target?

Ms Stuart : If hon. Members would listen, I might be able to finish a sentence.

We expect more ambulance trusts to achieve their targets. The London ambulance service is expected to achieve its target as quickly as possible, because that could save as many as 1,800 lives every year among people under 75 who suffer acute heart attacks. During

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the last three years, the number of calls to the London ambulance service has increased by 130,000--that is more than 12 per cent.

Mr. Hammond : Will the hon. Lady give way?

Mr. John William (in the chair) : Order. The hon. Lady has made it clear that she is not giving way.

Ms Stuart : That increase should be seen against the background of some of the worst traffic congestion in the country, so things are improving. Despite the difficulties of working in the busiest city and dealing with the highest number of calls, the London ambulance service has been making progress. In 1993, an ambulance responded in less than eight minutes to only 12 per cent. of the most urgent calls; by March this year, that figure is expected to rise to 55 per cent. Thus 190,000 more patients will be treated within eight minutes than were treated in 1993-94. However, that is not good enough. I have asked Neil McKay, the chief operating officer of the NHS, and John Bacon, the acting regional director of the NHS executive, to meet the chairman and chief executive of the London ambulance service to discuss how the 75 per cent. target can be achieved as quickly as possible and how good practice can be shared. That meeting is due to take place before the end of February.

I know that hon. Members are keen on the idea of increased resources for ambulance services. The Government are committed to providing a first-class public service. In answer to a question about extra payment, I stated:

Hon. Members : What is the answer?

Mr. John McWilliam (in the Chair) : Order. Hon. Members have been heckling and they must not do so.

Ms Stuart : In 2000-01, we invested an extra £21 million in the NHS ambulance service in England to help it to make continued progress. That money was for investment in extra vehicles and front-line staff. The funding was made available on a recurrent basis. This year an extra £6 million was given to the ambulance service in London to help it to improve its service. The total investment in the London ambulance service for this year is £120 million.

Mention was made of health authorities working together. They are working much more closely together and developing a three-year funding programme that will provide increased funding for the ambulance service.

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I welcome the London ambulance service's performance improvement programme, and I am pleased that staff have welcomed it. I was also delighted by the support for the chief executive. The extra investment will go alongside changes in the way in which the service is provided. It is not a question of simply buying and operating more ambulances.

Mr. Hammond : Will the Minister give way?

Ms Stuart : No. I want to make progress. The first service to reach the 75 per cent. target did so because it took a radical look at how it was providing its service. We expect that everywhere. Just paying more to do more of the same is not the way forward. Hon. Members know that, but it is easy to ask for more money. Improving the ambulance service is not just about ambulances. Planning to ensure that the right ambulances are in the right location is very important.

We need to work with information technology, as hon. Members have mentioned, but to do that we need the infrastructure. It is no good just providing one set of ambulances with telemedicine if they cannot link into the infrastructure of accident and emergency departments. That is why we are investing something like £1 billion over 10 years in infrastructure and information technology. That means huge progress.

Mr. Horam : Will the Minister give way?

Ms Stuart : No. I want to finish, because I am being accused of not answering questions and I want to make my point.

Hon. Members have graphically described the dreadful situation with regard to NHS and category C calls, and have raised the issue of how the ambulance

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service should respond to, for example, a babysitter who dials 999 because she has run out of nappies. They offered no solutions other than to provide more money. The question of inappropriate calls is being addressed by NHS Direct pilots dealing with category C calls, and by having paramedics on premises. Those projects are trying to categorise calls properly so that, as the hon. Member for Runnymede and Weybridge said, faster response times are possible.

We are investing in accident and emergency departments in London. More than £20 million has been invested in the past 18 months to improve through-flow and design. The London ambulance service has installed defibrillators in every vehicle, and plans to buy more than 400 more of the latest model, which has meant a great enhancement of monitoring and use in public places. The service is investing in more information technology--and I hope that it will do so more effectively than it did at the last attempt, under the previous Administration, because that did not work.

I want to comment briefly on the shock of seeing the paperwork that is still done in the London ambulance service. A move to information technology is being made, but the paperwork system is being run in parallel. When things went wrong in the 1990s, one of the big disasters was the attempt at a big bang--switching straight from one system to the other. The transition is now being successfully completed. Greater use is also being made of extra motor bikes.

There is still a long way to go, but the service has a huge contribution to make. The staff are responding to that challenge. We are providing the money to expand the service in a sustainable way. That is the way forward, not another call for more money for one group, which is what the Liberal Democrats repeat over and again. They want more money, but they do not know where it should come from.

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