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The other example, which the hon. Gentleman touched on, is the air ambulance, and it is quite a good parallel with the BASICS service. Until last year, the only local air ambulance service was the one in Thames valley, which I do not think has ever received a penny of public money. We now have our own in Hampshirethe Hampshire and Isle of Wight air ambulancewhich, again, I think receives no public money at all. One could say that that is slightly odd. The police have helicopters. No one has ever argued that the police should have a whip-round for police helicopters. They are an integral part of the police service, but specialist trauma response is another emergency service and, for some reason, its helicopters have to be funded in a totally different way. It is not immediately clear why that should be so.
Then we have BASICS, the service to which the hon. Gentleman referred. One could argue that the case for absorption of that service is stronger. With hospices and helicopters, there is something visible for which people can raise money, but for this service, there is nothing visible at all. It is an unseen part of the service. Therefore, one could argue that the case for total absorption and integration is stronger. It is very difficult to say that it is an acceptable risk for patients to rely on off-duty volunteers, possibly to save their lives.
Mr. Oaten: I am sorry to intervene so soon. I am grateful to the right hon. Gentleman for his speech on this issue. He reminds me about the ridiculous situation in which some consultants are on duty, operating and working in the accident and emergency department, waiting for emergencies to come in, and their pager goes off, asking them suddenly to switch to become a volunteer and go out. They cannot do so, because they are working in the hospital, and they have to wait for the patient to come in, knowing that if they had been able to go out as a volunteer, they perhaps could have helped to save a life. What better example is there of the fact that the service should be integrated?
Last year, the Hampshire service received the Queens award for voluntary service. I commend it for that. The hon. Gentleman referred to the National Confidential Enquiry into Patient Outcome and Death, which highlighted the inadequacy of out-of-hospital care. It said:
The current structure of pre-hospital management is insufficient to meet the needs of the severely injured patient.
I agree. It seems to me that the objective should be to integrate the service that the hon. Gentleman has described into a properly funded pre-hospital service, with doctors and paramedics working together as a team.
The debate calls for a ministerial response, and I am delighted to see the Minister in his place. He can say one of a number of things. First, he could say, These are wonderful people. I applaud what they do, and I would like to provide this life-saving service as part of the mainstream NHS, but the resources are not there, so we will carry on as we are. Or he could say, The case has been made. We recognise that, in most other countries, this service is an integral part of a national health service. We accept the case. We will make this a priority,
and either move ahead with earmarked additional resources or ask people to do it within existing budgets. Or I suppose that he could say that he wants to reach the same destination by another route; he wants progressively to upskill the paramedics, reduce the call-out times, put better equipment in ambulances and implement similar solutions. I am not sure whether that would achieve the same objective. The paramedics are fine. For the average call-out, they have the necessary skills, but as the hon. Gentleman said, they simply are not trained to the level of doctors.
The Minister might like to respond to this point. The new GP contract contains a provision for a national enhanced service for immediate care, but as I understand it, almost no primary care trusts have commissioned one, so there is a provision, but it is not being activated. This is what we need to know from the Minister. What is the philosophy? What is the policy? Should the service be a mainstream part of the NHS? If so, how will we get there, and as the hon. Member for Winchester said, who will pay for it?
I have a final point about the landing site in our area. The paradox at the moment is that, when someone called out under BASICS gets to the scene, there is almost always an ambulance there as well. If an air ambulance is summoned and takes the patient to Southampton, they then have to go by ambulance to the hospital, as the hon. Gentleman explained. The same ambulance that attended the initial incident then goes to the helipad, so there is no gain in time at all from using the helicopter. Given that paradoxical situation, there is an urgent need to make some progress with a more accessible helipad for patients who are taken to Southampton hospital. I am sure that the Minister will respond as sympathetically as he can, and I commend the hon. Member for Winchester again for raising the profile of this important but neglected subject.
I congratulate the hon. Member for Winchester (Mr. Oaten) on securing a debate on this important issue. He raised some interesting points. We are fortunate today to have an excellent Front-Bench team, and I am delighted to see the Minister in his place, as I know him to be a caring man. The Government have invested much more in health over the past decade, and I congratulate them on that. However, our constituents do not see a proportionate improvement in health outcomes. We are debating an area in which a little extra spending might give results that people would welcome; I ask the Minister to consider that point.
The hon. Member for Winchester mentioned the different approaches taken by various countries, and we clearly need to review the way in which we provide immediate, on-the-spot care for trauma patients. The hon. Gentleman focused on the first few moments of care. I want to extend that to the first few hours. He mentioned the importance of breathing, clearing airways and similar issues, but I want to focus on head injuries.
Research and experience indicate that there should be no more than four hours between injury and operation if there are expanding mass lesions, such as extradural or acute subdural haematomas. Only 20 per cent. of
patients with severe head injuries are treated within those four hours. The problem is not the one hour leading to the CT scan. That is usually met; the response is pretty good. The problem is largely with the inter-hospital transferfrom the hospital that first receives the patient to the specialist hospital capable of dealing with severe head injuries. That is where the problem lies.
The ambulance service and the hospital management team probably consider that, because the patient is already in hospital and in a secure and safe environment, the need to move the patient to another specialist hospital within the four hours is not so importantthe priority is lost or diminished. That perception is one reason why the four-hour limit is not met in 80 per cent. of cases. That should be a top priority. If that limit can be met, the outcome for the patient is so much better. However, when it is not met, the outcome becomes worse as time goes by. Many patients die who could otherwise have been saved; and others suffer severe and permanent disabilities who otherwise would not suffer them. Although it is important to treat a collapsed lung, once the patient is in hospital it will not kill them. However, a head injury can kill or cause permanent damage. We need to focus on that specific but small issue. I am sure that the Minister is listening carefully.
A good development that the Government are pursuing is the specialist trauma centre. Patients suffering multiple traumas are taken there in the first instance rather than to a general hospital. That is extremely helpful, because it does away with the inter-hospital transfer. The four-hour limit is more likely be met, and the outcome for patients with severe head injuries and other traumas will therefore be much better. I welcome and support the Governments move on specialist trauma centres.
The hon. Member for Winchester spoke of funding, and I shall follow him. One reason why the UK Independence party wants to repatriate the £15 billion cost of our membership of the EU is to invest more in specialist services, such as immediate trauma care and health care generally. That is another sound UKIP policy.
My hon. Friend mentioned Dr. Phil Hyde. Dr. Hyde has also spoken to me. He is clearly passionate about the subject, and there is a real issue over patient safety. I was taken aback and horrified by what I heard in my conversation with him. Before that meeting, despite shadowing ambulance teams on a number of occasions, I had no inkling that, if I were to be seriously injured in a road traffic accident, my prognosis would be severely affected by whether a voluntary doctor happened to be available. That is scandalous.
The 2007 report by the National Confidential Enquiry into Patient Outcome and Death entitled Trauma: Who Cares? has been mentioned. It concluded that the current structure of pre-hospital management is insufficient to meet the needs of the severely injured patient. It said that there is currently a high incidence of failed intubation and of people arriving at hospital with a partially or completely obstructed airway. It went on to say:
Change is urgently required to provide a system that reliably provides a clear airway with good oxygenation and control of ventilation. This may be through the provision of personnel with the ability to provide anaesthesia and intubation in the prehospital phase or the use of alternative airway devices.
Research shows that patients who die from severe injuries often do so within the first hour after the accident. In the United Kingdom, that hour has usually passed by the time the patient reaches hospital. However, sending a BASICS doctor to the scene of an accident is the nearest one can get to sending the hospital to the patient. BASICS doctors will often perform a specialist procedure, known as rapid sequence intubation, to help to stabilise the patient. Once the patient is stabilised, the doctor will be able to judge which is the best hospital for the patient.
The hon. Member for Castle Point (Bob Spink) mentioned the specialist trauma centres that are being introduced and said that the outcome for patients will be much improved if they can be stabilised and taken to an appropriate specialist unit. If there is no doctor on the scene, such patients suffer a double whammy. They will not have been stabilised at the scene, so it is often decided to take them to hospital quickly, but the nearest hospital may not be the most appropriate. We all know that some hospitals excel at certain aspects and some at others. Many patients are therefore not given the greatest chance of recovery.
As someone who has probably overdosed on episodes of Casualty, I was surprised to learn that accident and emergency consultants are not generally in the business of donning hard hats and bright protective clothing and going to the scene of accidents. I asked, Isnt that what happens? I was told that they could not leave the casualty department, although some are BASICS doctors in their spare time. Not everyone who works in the casualty department is suited to working on the road.
In the casualty department, there is plenty of light, the equipment is where it is needed and there is space to operate on the patient. At the scene of a car crash, one has to work with the noise of the machinery and the fire engines in a confined space; it is a completely different environment. I understand that not everyone can operate easily under those conditions. Those who do so are a special breed.
Most of the doctors who provide the BASICS service are fully employed in the NHSsometimes in A and E, as I said, but often in other disciplines, such as intensive care or surgery. BASICS doctors are particularly valuable in providing complex airway management procedures and stabilising patients in a critical condition.
BASICS doctors work closely with the ambulance service when a multi-agency response is required locally or when additional skills and qualifications are needed. They are usually called when a paramedic decides that he or she does not have the training to deal with an incident. The paramedic who arrives at the scene will often call the BASICS doctor, although in the case of a fatal crash, the control centre will sometimes call them out.
An industrial accident involving a worker who has become trapped in machinery is a good example of what happens. The ambulance service would work alongside the fire service to co-ordinate the rescue. BASICS could supplement the skill set available at the scene by providing a medical doctor with the necessary extra skills. If necessary, the doctor may use a surgical procedure to extricate the patient, although that is obviously a last resort.
I know Hampshire best, and it is where I have the best figures from, so I will use it as an example. As the right hon. Member for North-West Hampshire (Sir George Young) said, the county has 19 volunteer doctors and one consultant nurse for a population of more than 1 million. Those BASICS staff work on their own time and carry a pager that is activated by the ambulance control in Winchester. Once paged, they must travel to the scene of the accident in their own cars, using blue lights and sirens. BASICS staff must provide not only their own transport, but all their own equipment. It can cost up to £25,000 fully to equip one of those doctors. Frequently, some of the money comes from the doctors own pockets, although staff do not really have much time for fundraising between doing their day job in the NHS and volunteering in their spare time.
Let me give a few statistics. In Hampshire, BASICS doctors are usually called out between two and eight times a day. There were about 1,200 calls last year, and BASICS doctors managed to attend 750 of them. We can only hazard a guess about what difference they might have made in the 450 cases in which no such response was possible.
Perhaps I can give a snapshot of what the BASICS staff do. In January, they responded to 58 calls, although I do not know how many they were unable to respond to. Two thirds of the calls that they responded to involved motor vehicle collisions. The others involved falls, burns and machinery accidents. In 16 cases, the doctor was required to give anaesthetic drugs. In 10 cases, they provided advanced wound management and life-saving minor surgery, as well as injecting drugs into the aorta. I mentioned the importance of admitting patients to the most appropriate hospital, and 26 of the 58 patients had their destination altered, because of the knowledge and expertise of the BASICS doctors.
Things vary throughout the country. In Sunderland, which has one of the best survival rates, the death rate for people coming into the unit is 2.9 per cent.half the national average. Bosses from City Hospitals Sunderland NHS Foundation Trust say that that is due to high investment in staff and facilities. Interestingly, the trust has also introduced a new trauma response team, and the figures speak for themselves.
It might also be worth mentioning London, which seems to have more advanced provision than many areas of the country. Specialist trauma teams are funded by, and travel with, the London air ambulance service. As my hon. Friend the Member for Winchester said, however, the air ambulance stops flying at night for some reason, and some of the provision then becomes voluntary. I am told that there are also only 15 BASICS doctors in London, covering a population of 8 million people. The moral of the story appears to be that, if someone is going to be involved in a serious accident,
they should make sure that it happens in London during the day, so that they have the best chance of receiving specialist care.
Clearly, there are many political priorities, and I can understand why there is not a huge patient lobby banging on the door to raise this issue. The Government could therefore quietly ignore the problem or dismiss it with the old chestnut that, This is nothing to do with us. Were trying to get these decisions taken locally. However, we need to take a more strategic approach to determining which specialist services are provided and where. People do not have accidents along primary care trust boundaries, and the issue is a real example of a postcode lotteryI hate using that term, but I have never seen a better example of one.
The fact remains that investment in this volunteer service can save money in the long term, because patients will have better outcomes and be less likely to need intensive post-trauma support packages or access to other benefits. The Government presumably have an interest in keeping their citizens safe and well.
I want now to summarise the national inquiry. The inquiry noted that the standard of care received by 60 per cent. of patients was less than what was judged to be good practice, and deficiencies were identified in organisational and clinical aspects of care. Difficulties were highlighted in identifying patients with an injury severity score of more than 16. Again, if such things are done properly, it will optimise the use of precious resources. Problems were identified not only with immediate pre-hospital care, but with trauma team responses generally and with the seniority of the staff involved once someone actually got into hospital. People were frequently not seen by a consultant within the first 12 hours, even though they were probably among the most injured patients in the country. Problems were also identified with immediate in-hospital care and the provision of suitably qualified staff at all times of day and night.
The report made a number of recommendations. It identified the need for designated trauma centres, and I acknowledge that we have had some movement on that. It also asked for a verification process to be developed to guarantee the quality of care. The report referred to the pre-hospital management of airways, which I have mentioned. It stated that a trauma team should be available 24 hours a day, seven days a week. It also noted that a consultant should be the team leader for the management of severely injured patients. The report also made recommendations about the nature of CT scanning once people were in hospital.
As has been highlighted, this is not a new problem. One of the most depressing things that I read was that the Royal College of Surgeons had looked at this issue in 1988 and 2006 and said that there had been no progress. It noted:
most of the improvement in the outcome of these patients occurred prior to 1995, with no further significant change occurring between 1994 and 2000.
Also pertinent to the debate is the NHS emergency planning guidance, which contains principles for effective emergency health planning. The chief executive of each NHS organisation is responsible for ensuring that it has a major incident plan in place. Given what we have
heard about trauma response, it is somewhat ironic that that major incident response could apparently also hinge on the availability of volunteer doctors.
The situation that I have outlined is not sustainable in the long term. I hope that the Minister is sufficiently persuaded by what he has heard today to commit to improving services. Put simply, if any of us or our constituents ever need trauma care, we surely deserve the best.
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