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The matter was first raised with me last summer, not long after I was elected, following an incident in the town of Newent. It was drawn to my attention that there was insufficient ambulance coverage. Normally one ambulance and crew was on duty, and sometimes not even that. I took the matter up with Gloucestershire Ambulance Service NHS trust, which confirmed that at timesspecifically, Sunday 17 Julyonly a single responder was on duty at one ambulance station. The decision was taken to team up the member of staff from Newent with the person in Staverton, and the coverage for part of my constituency was therefore provided from Gloucester.
The ambulance trust confirmed in its letter that it used a matrix system, taking historical data as a basis for placing vehicles in the area from which the next call was expected to come while preserving geographical cover. I contend that it might well do the former, but it does not adequately do the latter. It does not preserve geographical cover across the county. One hint of the problems associated with its management information systems was its confirmation that it uses a paper-based system to manage the process, whereas more complex, but more efficient, computer systems are available. To be fair, it also confirmed that the strategic health authority had awarded it £500,000 to invest in the latest technology, which would have more effective facilities for moving ambulances around.
Following that, in January, I received a letter from a concerned paramedic somewhere in the county, expressing the concerns of many paramedics about the matrix system for allocating ambulances. It was clear that resources were being diverted from the Forest of Dean and other rural areas, primarily to cover Gloucester and Cheltenham. I wrote to Philip Selwood, chief executive of the ambulance trust, enclosing a copy of the paramedic's letter, and asked him to comment on some of the areas of concern. I said that it appeared from the letter that the matrix system was not appropriate or that the trust did not have the resources to cover the county properly. I also asked him to comment on how the proposed merger between the ambulance service trusts of Gloucestershire, Avon and Wiltshire would affect emergency coverage.
Mr Selwood comprehensively answered my points in a letter dated 20 January. However, his answers made the situation appear worse rather than better. He confirmed that the trust used a matrix system, saying that it was in place in order to provide optimum cover throughout the county. However, he confirmed that Gloucester and Cheltenham had top place on the matrix, so that they were covered, rather than lower call-volume areas. I asked whether he could say how often my constituency was left without adequate ambulance cover. The situation was a problem, but even more worrying from my point of view was the fact that he was not able to answer that question because the technology and reporting systems were not in place to provide that level of information.
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That was worrying in two ways. First, it is always worrying when large organisations that do not have adequate management information to make key decisions about the allocation of resources, make such decisions anyway. That is a concern in the 21st century. Secondly, the matrix system, by its nature, depends on the ability accurately to forecast where emergency calls are likely to arise and therefore where to locate the ambulances across the county. If the trust's management information systems are so poor that Mr. Selwood cannot even tell me how often my constituency is left without adequate ambulance cover, I am not sure how they can operate such a system with any confidence that it will locate ambulances where they are likely to be needed in most cases.
Mr. Selwood told me that the project to use £500,000 from the strategic health authority to replace the computer-aided dispatch and management information systems and to place mobile data terminals in the accident and emergency vehicles was scheduled for completion in November. He confirmed that the trust would then have an enhanced reporting system capable of meeting my requests for information.
The letter that I received from the paramedic suggested that if Cheltenham and Gloucester ambulances were busy, vehicles would be pulled in from other areas of the county, which would leave some areas with no ambulances to cover them. Mr. Selwood stated in his letter:
"I can confirm that this is the basis of our operating regime; once a vehicle leaves a matrix point that is high in the priority order then an ambulance is moved into the area from an area that is less likely to receive a call. This makes best use of our limited resources."
To be fair, Mr. Selwood also said that the trust has recently introduced an urban response scheme in Gloucester and Cheltenham, with four vehicles based in those city areas, the purpose of which is to reduce the number of occasions when vehicles would have to be moved from rural areas into the urban areas of the county. That has just been doneor is still in the process of being doneso I have nothing to show whether it has made any difference.
The letter from the paramedic also referred to a fatal road traffic collision in the Forest of Dean, in which one person died and six others were injured, treated and taken to hospital. The trust did a good job in one sense. The first vehicle on the scene came from the Cinderford ambulance station and was there within 13 minutes. However, the accident required a further three vehicles, which had to be dispatched from Gloucester and Cheltenham. I am still waiting for the reply about how long those ambulances took, but given the geography involved they would have taken between 30 and 45 minutes to attend the scene.
I would be grateful if the Minister commented on the subject of community responders, where there appears to be a bit of confusion. The paramedic who wrote to me said that ambulance management will argue that community responders provide better patient care, but that they simply give management an excuse to pull ambulances into Gloucester and Cheltenham by having someone who is willing to make the first response in an outlying area. I specifically asked the ambulance trust to comment on that, and Mr. Selwood said:
"the government set standard is to provide an appropriate response to patients within 8 minutes for 75 per cent. of all occasions; this response can be a trained Community Responder with a defibrillator."
Community responders mean that the ambulance trust can have the community responder respond in the first instance. The trust then has 19 minutes, rather than eight, in which to supply an ambulance. There is a great temptation for an ambulance trust to put community responders in place, not in addition to, but instead of a properly resourced ambulance network for accident and emergency. I would be grateful if the Minister commented on that.
Mr. Selwood also said that the ambulance trust is in the process of reviewing its response matrix to make best possible use of the vehicles available. He said that they are seeing a year-on-year increase in activity of 8 to 10 per cent., which is putting a strain on their resources, and that there are times when they would benefit from additional resources.
That new type of service refers to the Government's agenda to recognise that only 10 per cent. of 999 calls are for cases that are truly life-threatening and to help the trusts to deal with those more adequately and to move away from becoming a transport service. Given the level of service at the moment, there is a great deal of scepticism in my constituency about whether that will be successful.
A number of concerns remain, subsequent to that letter, as the Minister can tell. I wrote to Mr. Selwood again and asked whether, despite the fact that his management information systems do not allow him to confirm exactly how often my constituency is left without adequate ambulance cover, he could give me some idea of that, even if only approximate. As part of the problem is the difference between urban and rural areas and the fact that the more densely populated areas have higher levels of ambulance cover, I have also asked him to comment on whether now that the large urban conurbations of Swindon and Bristol will be included in the new tri-trust area the pressure on rural areas will be exacerbated. Mr. Selwood has unfortunately been away, although I am due to meet him this coming Friday. I hope that I will get the answers to my questions then.
I want the Minister to cover some specific questions. First, can she justify the matrix system used by the ambulance trust? It seems to leave certain areas of the county, particularly rural areas such as my constituency, without proper cover and may put lives at risk.
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Secondly, how will the merger of the Gloucester trust with the Avon and Wiltshire trusts affect the Forest of Dean? We are on the edge of the county, next to the boundaries with Wales and Herefordshire, so are we particularly likely to lose out, as a number of my constituents suspect?
I have already drawn attention to the potential effect, linked with the merger, of the incorporation of Swindon and Bristol. If the three ambulance trusts, when merged, have a single method of prioritising cover and a single matrix system, which includes those two extra-large urban areas, will my constituency effectively be left out on a limb with marginal ambulance cover, and will we have to rely on ambulances being sent great distances from those urban areas to respond in emergencies?
The chief executive alluded to one further area that my constituents find it difficult to understand. I am happy to acknowledge that taxpayers are paying a great deal more tax, which is going into the national health service. If we look at the figures at a national levelI would be grateful if the Minister told me whether the same is true in my constituencythere are more ambulance staff and more resources. My constituents find it difficult to understand that, given that resources on the ground seem so patchy. That is one of the central questions.
Finally, my constituents pay their fair share in tax for the national health service. They deserve proper ambulance coverage and accident and emergency coverage; they deserve the same as in other parts of our county and our country. They do not seem to be getting it, and I would be grateful if the Minister told us what she and the Government plan to do to put the situation right.
The Parliamentary Under-Secretary of State for Health (Caroline Flint) : I congratulate the hon. Member for Forest of Dean (Mr. Harper) on securing the debate on ambulance coverage in his constituency. It is a matter of concern to him and his constituents. My constituency of Doncaster is not the same as the Forest of Deanit is a former mining areabut the South Yorkshire ambulance service has issues in common with his, both in the urbanised areas of Sheffield and the surrounding rural areas of Sheffield, Barnsley and Doncaster.
Getting a balance of service in the servicing of rural, semi-rural and urban communities is important. That is one of the reasons why, as I have seen as a constituency MP, the ambulance service has addressed these issues in more recent times by finding better ways of operating, such as parking ambulances in different areas and sharing services with fire stations and others in order to create a service fit for purpose.
I am sure that the hon. Gentleman would agree that it is unfortunate that a large number of people still dial 999 in non-threatening situations. In some cases, there are hoaxes; I know this because a few years back, when I was first elected, I spent some time in the control room listening to calls as they came in. There are other reasons for such calls: sometimes people feel that the quickest way they can see someone is to ring 999 and get an ambulance to take them to accident and emergency.
Considerable work is taking place in relation to out-of-hours services and walk-in centres, but also with people responding who can deal with treatment at
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location. The ambulance service is looking at such different methods around the country and considering its partnership with other health service providers to determine how it can meet needs in the right way.
About 6 million people call 999 each year, and ambulance trusts are the first and most important contact for many people ringing that service, especially if their illness or accident requires it. The range of care provided has been expanded, providing an emergency response but also urgent advice or treatments for patients who are less ill, and care for those whose cannot easily travel to access health care services. The ambulance service has grown in recent times to find different ways of meeting the needs that only their specialist service can provide. I pay tribute to all staff in the hon. Gentleman's area, and throughout the country, who continue to help us to deliver a very good health service.
Ministers recently approved the merger of three small ambulance trusts to form one trust serving the whole of Avon, Gloucestershire and Wiltshire. The new trust should be established from 1 April 2006, and the three existing trustsAvon ambulance NHS trust, Gloucestershire ambulance NHS trust and Wiltshire ambulance NHS trustwill be dissolved. As part of that process, the Avon, Gloucestershire and Wiltshire strategic health authority has been reviewing the configuration of ambulance trusts since January 2005, against a background of weak performance in relation to response targets from all three trusts.
The hon. Gentleman's points are perfectly legitimate, and were part of the reason why it was felt that merging the trusts would help in several different ways. The hon. Gentleman gave an example about management systems for collecting data and asked whether IT systems are being put to the best possible use. It is hoped that a bigger trust will make modernisation and reform in such areas more possible.
A three-month consultation was undertaken between July and October 2005, ahead of national consultation on ambulance trust configurations. The main driver for merger of services in this area was poor performance by the trusts as regards achieving the category A standard, a point emphasised by the hon. Gentleman. For example, in Gloucestershire in 200405, the percentage of category A calls receiving a response within 8 minutes was 71.2 per cent., falling short of the 75 per cent. target. A performance improvement plan has been developed and implemented to improve response times and patient care in Gloucestershire. For example, in the Forest of Dean, community responder schemes have been developed in partnership with St. John Ambulance, with a scheme in Coleford, and a further two teams planned for Cinderford and Newent.
There is clinical evidence that proves conclusively that early defibrillation and resuscitation saves more lives. We acknowledge the valuable support that community responders offer to ambulance services locally. They are trained in life support and first aid and equipped with defibrillators. The use of first responders can ensure that patients receive advanced life support as soon as possible, which we all welcome.
Although the initial emergency response may be to send a rapid response vehicle or an improved first responder, a fully equipped ambulance vehicle, able to
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transport a patient in a clinically safe manner, is still required to attend the incident within 14 minutes of an initial call in urban areas and 19 minutes in rural areas. It is a local matter for trusts to decide how or where they use community volunteer responders, or other schemes such as community paramedics, as well as other resources, such as traditional ambulance provision. Rapid response vehicles, or motorbikes, for example, are one way to ensure a timely response, but the most important thing is that aid gets to the person involved as soon as possible.
There has been a review of the operational periods for the Newent, Lydney and Coleford vehicles. The Newent vehicle now operates on six nights a week, when it previously operated on three, and the Lydney vehicle now operates on six nights a week, when it previously operated on four. The Coleford vehicle now operates on seven nights a week, when it previously operated on four as well. I hope that that reassures the hon. Gentleman and will form part of his conversation with the chief executive later this week. Those attempts have been made to ensure that there is better operational coverage by those important vehicles.
The trust recently purchased eight new replacement accident and emergency vehicles, one of which will be based at Coleford, with a second vehicle at Newent, both covering the Forest of Dean area. The Lydney ambulance station also has a new patient transport service vehicle. The trust is continuing its work with colleagues in the police and fire service to examine how they can reduce deaths in the Forest of Dean area from road traffic collisions.
The hon. Gentleman referred to a particular case and expressed concern about the time an ambulance took to arrive at the scene of a car accident, only to be followed up by three ambulances. I asked officials to check that situation, and I understand that the accident was initially reported as a category B incident, rather than category A. That may be one reason for the amount of time the first response vehicle took to arrive. Obviously, once it had arrived, an assessment of the situation could be made, which may have changed between the point at which the call came in and when the ambulance arrived. A further three ambulances were then called for. Technically, it was not necessarily the case that the ambulance exceeded its time target; it was more a question of how the accident category was reported in the first instance.
A performance improvement plan has been developed, and I have outlined a few of the areas in which attempts are being made to improve the service. Action is being taken to improve capacity in Gloucestershire as a whole, including four mobile doctors to respond to category A calls, urban responders in Cheltenham and Gloucester, and emergency care practitioners handling 999 calls in the control room to reduce the need for a face-to-face response. I am sure that the hon. Gentleman would agree that that is a valuable service.
It makes more sense for people in urban or rural areas, who need to get an ambulance out as soon as possible after a call is made, if someone in the control room can assess their needs and deal with them over the phone,. I understand why some people make certain calls but they are not always the most appropriate for a 999 response Unlocking some of the jams in the system is one of the ways in which we can try to manage things
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and ensure that people, wherever they live, get the service fit for their need in an emergency. The new ambulance trust will support those improvements to the level and type of service provided to users, while obviously looking at greater capacity and opportunities for flexibility and shared learning.
The hon. Gentleman referred to the matrix system used to plan where resources should be used and situated. He is right. It is not new to his area; it is a long-standing system for planning where ambulances should be. It is one of the reasons why, in recent years, we have had more discussions about ambulances being out on location, rather than stuck in ambulance stations, and about resources shared with fire and police services as a means to facilitate the needs of staff, so that they are not just stuck in a lay-by eight hours a day. Part of that process has involved trying to consider the number of calls and where they come from.
The system has been used historically, and it has been helpful, but I understand that work is being done to look more closely at how the matrix works. Returning to my previous point, one area that might be considered is the number of calls that come in from a particular area and how many of them really are category A calls, as opposed to calls that should have been dealt with through health provision in the community. It is worth considering that issue. If we can bring down the number of calls that result in an ambulance being wrongly sent out, that will give more room for management and service providers to think about how they will meet the needs of the more rural areas, which are more difficult to get to because of the surrounding roads and so on. That would be helpful, and I am sure that it would be helpful if the hon. Gentleman talked about those issues with the chief executive when he meets him later this week.
The national picture has an impact on the local picture. The Government's spending on ambulance services has increased from £617 million in 1997 to £1.2 billion in 200304, an increase of more than 75 per cent. It is always important that people look at what we have now. I can understand people wanting more, but it is important to reflect on the situation in the past, which might not be in their living memory, and the lack of investment then.
We felt that it was right to set a standard that at least 75 per cent. of 999 calls for immediate life-threatening conditions should have an ambulance response within eight minutes. In 2001, fewer than 71 per cent. of those calls were responded to in eight minutes. Over the past two years, performance against that call standard has exceeded 75 per cent. Surveys that we have carried out with patients show that 98 per cent. are overwhelmingly satisfied with the care that they receive. That is in the face of consistently increasing demand for ambulance services. Our funding reflects our understanding of that, but we also understand that the issue is not just about funding; it is about modernising and reforming the service to ensure that it provides the right service for the right sort of need.
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I am pleased that there has been a demonstrable improvement in patient care, particularly in cardiac care. We are confident that, while recognising the local issues, larger trusts will deliver a better, more responsive, more efficient service, which people have a right to expect.
Although progress has been made nationally in the ambulance service, we know that the contribution ambulance trusts could make to the wider health agenda has not been fully utilised. That is why we appointed Peter Bradley to lead a strategic review of ambulance service delivery, "Taking healthcare to the patient: Transforming NHS ambulance services", which was published last June to widespread support. The review sets out a compelling vision for ambulance services and makes recommendations in five key areas: improving clinical and managerial leadership to match new models of care, improving the consistency and quality of care provision, improving efficiency and effectiveness, supporting performance improvement, and developing the work force.
The benefits of delivering that vision will include patients receiving improved care, with potentially 1 million fewer unnecessary accident and emergency attendances; greater job satisfaction for staff as they use their additional knowledge and skills to care for patients; a more effective and efficient use of NHS resources; and improvements in self-care and health promotion.
We know that patients calling 999 are a mix of those with clinically urgent needs and those who view their condition as urgent. The report makes it clear that ambulance trusts need to widen the range of services that they provide. They need to work closely with other urgent care providers so that alternatives can be found for patients who do not need an ambulance. Some of those can and should be delivered by the ambulance service, but it is clear that some should not. In taking the report forward, we are building on the excellent service already delivered and the dedication and skills that have made the service what it is today. It is important that our vision sets out a service that will deliver the best possible care to patients.
The work that has been done in the past 12 months to move to merge the three trusts is a step in the right direction. Clearly, more discussion is taking place on providing services, particularly in the rural parts of the area covered. As I said before, I understand that there is some work considering the matrix, the number of calls, their nature, and what problems that may present for operational management.
I am sure that the hon. Gentleman agrees that people need a prompt and efficient ambulance service. Such a service should be based on the need of the individual. We must ensure that other calls do not get in the way of providing that prompt service to his area, my area and the rest of England.
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