Examination of Witnesses (Questions 980
- 999)
WEDNESDAY 17 APRIL 2002
MR GRON
ROBERTS OBE AND
MR PETER
BRADLEY
980. How much training goes on with those who
are specialists in this field?
(Mr Roberts) Again London is different, so I will
let Peter answer for London. Generally, the training has been
fairly local. We have not got a national doctrine, so what do
you train in unless you know what you are training for, so I think
there should be a step-by-step approach. Once we have the doctrine
and the operational procedures in place, there needs to be a robust
training programme. If you take the police, for example, there
are 6, 8 or 10 people at Winterbourne Gunner paid full-time to
take out the training to the police service. We have been able
to borrow somebody from the London Ambulance Service and put him
down there part-time for a few months, but there is a cost attached
to it. Those are the kind of things we need to deal with with
the Department of Health.
(Mr Bradley) The training is a week's course at Porton
Down but I think the police and fire are looking to set up a centre
of excellence at Winterbourne where there will be a training centre
for these types of incidents. All three services, we understand,
will have access to that training. The London Ambulance Service
training is a week-long training course and, helpfully, our specialists
have had the opportunity to go through the white powder exercises,
which was invaluable experience, since last September.
981. What is your target level of those trained
to deal with this?
(Mr Bradley) 150 by the end of July.
982. And as a percentage of the service?
(Mr Bradley) That is around 7 per cent.
Mr Howarth
983. Can I ask you an ancillary question on
this. You have spoken about the difficulty of ambulance staff
working in this equipment and the difficulty of communicating.
Can you tell us about this at a practical level? How is a member
of the Ambulance Service working in this cumbersome kit going
to be able to communicate with the patient?
(Mr Roberts) You can actually speak in the kit we
have, it is not gas-tight. What we found with gas-tight kits was
that you cannot communicate at all with the patient. The kit we
have is a ventilator kit with air flow so you can speak to the
patient, although with some difficulty. That is going to be particularly
important in terms of people who are frightened, who are trying
to be decontaminated; you really do need to do that. We did have
some practical experience of that in London because we did decontaminate
a reasonable number of people after the white powder incidents,
and you can communicate with them. But there are other things
as well. If you are going to do any treatment, you have to be
able to feel, and you either have to compromise with your gloves
or have two sets on.
984. So there are some real, practical difficulties
there which the national doctrine needs to address?
(Mr Bradley) Yes. There are things like using warm
water rather than normal cold water for hypothermia. There is
also the fact we have to undress all the casualties completely,
which is quite disconcerting, so it does require a degree of expertise
and understanding by both staff and by the casualties.
Chairman
985. Thinking the unthinkable, if there is an
absolute catastrophe and there were 30,000 casualties, how the
hell would you fit into that process? What role would you have?
(Mr Bradley) That is one of the big issues now which
is exercising our minds. Mass decontamination is a huge problem
because the through-put of casualties through a proper decontamination
process is something in the 20s per hour; small numbers. So when
you get into an incident involving thousands, a whole host of
things are being considered, for example, using sprinkler systems
in multi-storey carparks and things like that. We do not have
a solution for mass decontamination. As Gron Roberts has said,
trying to herd, as it were, patients or casualties through a process
in itself presents practical difficulties. What we have found
from previous experience is people are self-presenting to A&E
departments who are then contaminating the accident and emergency
departments, so there are huge issues which remain at this stage
unresolved. We are working through them.
986. When will they be resolved?
(Mr Bradley) To be frank, I am not sure the scenario
we have just talked about can be resolved. Is that fair?
(Mr Roberts) Yes. Human nature is to run away from
these incidents and then go to where you would normally seek treatment,
your local hospital. The sarin incident showed us that self-evacuation
is going to be a big problem, and therefore however good our plans
at the front end, hospitals are going to have to do something
about decontaminating at hospitals. There is not much evidence
around about decontamination, not in a civilian way anyway, so
we do not know what the best method is or how much is really necessary.
Some people say that with many of the gases, for example, by the
time you come to decontaminate, if you take their clothes off,
80 per cent of the contamination will have gone anyway. There
is a lack of research evidence to say this is how we should do
these things. We are learning by doing and we are getting better
every day.
987. Seven or eight months after the crisis,
one would have hoped that some thinking would now be a little
more concrete.
(Mr Roberts) I suppose one could hope that, that might
have been the case. I think we are still distilling the lessons,
we really are.
988. But if a fresh crisis had come on fairly
close to the 11 September incident, we would have been caught
totally unprepared. There is a limit to the time one can pontificate
on options and taking action. So far, fortunately, nothing has
happened but there was no God-given certainty there would be no
incident in this country after Washington and New York.
(Mr Roberts) 11 September was not a chemical or biological
incident.
989. No, but there could have been a catastrophe.
(Mr Roberts) I suppose we could argue that where we
were a bit slow, and I would accept it, is that the sarin attack
happened in 1996 in Tokyo and we are now running to catch up with
the chemical lessons which we have had a lot longer to learn.
As I say, emergency services in this country are quite good at
dealing with major incidents, but with major catastrophes with
5,000 patients, the planning scenario shifts. You might do that
if you are in Italy or Greece or Turkey where they have earthquakes,
but we are not particularly well prepared in this country for
that kind of casualty number.
990. You feed into this civil contingency planning
operation, and no doubt you would be an integral part of the process,
but do you think local authorities are the best organisations
to deal with major, major catastrophes, or might there have to
be some other form of structure established, such as central government
imposing structures if it is deemed local authorities can really
only cope with the crisis up to a certain level?
(Mr Roberts) I am not sure it is a structural issue.
I think it is about how people work with each other. In a sense,
if you look at the Health Service, it is outside the local government
system as well, so wherever you draw boundaries there will be
problems. What I think 11 September has brought home to us is
that although the local approach to major disaster planning is
still probably where things are most effective, CBRN incidents,
large-scale incidents, disaster-type incidents, will need a national
focal point, will need much more joint work than we thought in
the past. I suppose the floods and other things which have happened
in parts of this country had also started to shift our thinking
to, "This will be beyond the capacity of one local ambulance
service, one local health authority", so is it about creating
a parallel structure or is it about making sure the structure
we have learns to work well together.
991. That is an interesting point, thank you.
(Mr Bradley) I want to say during the six months when
we did have the white powder incidents, London Ambulance Service
did respond to other counties to help deal with their incidents.
I think it is, as Mr Roberts has said, about mutual aid, having
good arrangements in place. I think most services suffer from
a degree of parochialism and there is a need to recognise that
there are times when you cannot cope and services cannot expect
to be able to resource up for those very rare events and therefore
we have to have good robust systems for mutual aid.
Mr Howarth
992. The Chairman said that we are now seven
months on from 11 September and I will be interested to know whether
you feel there really is a sense of urgency in tackling this?
You have outlined to us this afternoon quite a range of difficult,
technical issues which need to be addressed, the need to establish
a national doctrine. We could have been subjected to an attack,
we could be subjected to an attack now given that we are deploying
combat troops into Afghanistan. Do you get a sense from your perspective
as the Ambulance Service that there is a real sense of urgency
to resolve these matters and they are not being allowed to drift?
(Mr Roberts) I do get a sense that there is still
a sense of urgency. The sense of urgency was heightened post 11
September, it was running at fever pitch for a few weeks. There
is always a danger in these things that we are 12 months on and
nothing else has happened and all the enthusiasm disappears; I
do not sense that this time. I sense that there is a real engagement
with the issues. Some of the issues are not amenable to short
term fixes and there are still issues about funding.
993. As long as we are clear there is a sense
of urgency around. That is the answer to the question.
(Mr Bradley) Can I just add to that. I think the important
point is for us all to recognise that issuing personal protection
equipment to ambulance staff, that could be seen as a quick fix
and that is not the answer. It is important that the impetus is
maintained once the equipment has been issued because it is more
than just that, it is the ongoing support.
994. We were talking a moment ago about decontamination
and there has been a change in the responsibility from your Service
to the fire service. I understand that the Department of Health
and the fire service have recently agreed a memorandum of understanding
which gives the fire service responsibility for decontamination
of mass casualties accompanied by around £50 million extra
funding to enable the fire service to equip itself for this role.
Were you consulted about this change? Would the Ambulance Service
have preferred to have retained that role if the appropriate resources
had been provided to you rather than the fire service?
(Mr Roberts) Were we consulted? Yes, I think we were
party to the discussions. The memorandum of understanding as I
understand it does not give the responsibility to the fire service.
The responsibility for decontaminating casualties remains with
the Department of Health and in small numbers it remains with
ambulance services and they have just been issuing equipment for
us to do that. Where the fire service comes in is where there
is mass decontamination, where basically everybody knows the quantity
of water that is needed to squirt all these people down. Yes,
they have been given £50 million which we would have liked
as well and we have still got arguments about money. At the end
of the day, I do not think we have delegated the responsibility.
What the memorandum of understanding says is that they will support
the health service in doing that. As the Ambulance Service, we
still see it as primarily our responsibility. We will welcome,
certainly, their assistance when there are mass casualties involved.
Many of these people will be victims rather than casualties. We
may need to start differentiating between people who are or might
have been contaminated but are well and those people who are injured
or ill as a result. As Mr Bradley says, with decontamination units,
particularly if you have got stretcher cases, you are going to
be lucky to put 20 to 30 people an hour through those things whereas
if people have just been in the general area, you squirt them
with water, that is mass decontamination.
Chairman
995. I was just pondering if there was a major
disaster, 30 an hour.
(Mr Roberts) It would take us a long time.
996. It would take some time before you had
got through the number of people.
(Mr Roberts) Yes.
Syd Rapson
997. You have talked already about your pride
in the NHS and hopefully in a few minutes we will be doing something
positive as a Government to assist in that. Can I go on to the
emergency planning review. There was a review which came out The
Future Emergency Planning in England and Wales and there was
a consultation period until October last year. Most respondents
were very supportive of local authorities having a lead role and
the ambulance, for example, being a partnership in this arrangement,
a sort of secondary position. 80 per cent of the respondents were
fire and police, and it is not usual with local government backgrounds
that they favour this. I wanted to tease out are you happy to
support the proposals to be in this partnership arrangement with
the local authorities having a lead nationally?
(Mr Roberts) As I said previously we were not consulted
and that in itself was an issue. We have made that point to them.
Yes, generally, I think the public safety agenda is something
which the Ambulance Service have a part to play in, as do other
health services, but we also have a health service agenda to discharge.
We work in partnership with local authorities day by day by day
on accident prevention, on campaigns of various kinds, and we
are very comfortable quite honestly in terms of local authorities
having the overall strategic responsibility for public safety
in their area. We do not have an issue on that.
998. When you say you were not consulted, was
it open for any consultees to put in information or were you waiting
for someone to say, "Have you got a view on this"? Most
consultations would be pretty widespread and would say, "Have
you got something to say?"
(Mr Roberts) I am not actually sure what the consultation
process was. We managed to get hold of the consultation document
after the closing date. You may say that means we were not very
pro-active, but I do not think we knew the exercise was going
on. That is typical because health services are health and local
authorities and emergency planning are in a different silo sometimes
in departments.
Syd Rapson: You have been very loyal.
Mr Cran
999. Just two questions, because time is pressing,
on the Civil Contingencies Secretariat. That is pivotal in the
situation we are in at the moment, the bringing-together, doing
the thinking about what we do and how we react and so on and so
forth. Can you tell the Committee what your experience of the
CCS has been and your participation in it?
(Mr Roberts) Our participation in it more latterly
has been increasing by the day, so we have been asked and involved
a lot more by them than we were. Again, we were swept up in this
business of, "Ambulance is health, is it not, so if health
is there, so is the ambulance service." What we have been
trying to say to them in the past three months is that is an assumption
they should not make. We welcome the fact there is a cross-government
focus on emergency planning and contingency planning because it
is the only way and we are looking forward to working a lot more
closely with them.
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