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11 Jun 2008 : Column 79WH—continued
10.19 am
Mike Penning (Hemel Hempstead) (Con): Let me declare an interest at the outset as a trustee of the new Essex and Herts Air Ambulance Trust and a patron of St. Francis hospice in my constituency. I will say a little about hospices later.
I congratulate the hon. Member for Winchester (Mr. Oaten) on his passionate and articulate speech on this important subject. He raised so many issues in his short contribution that it will be difficult to address them all, but I hope that the Minister will deal with many of them and perhaps some of those raised by other hon. Members.
My right hon. Friend the Member for North-West Hampshire (Sir George Young) spoke about the hospice movement. There is an obvious link between that movement and the sort of voluntary medical care that we have been describing. My right hon. Friend alluded to the fact that the hospice movement is being drawn closer to the NHS, because of their funding streams; but one of the biggest concerns of my local hospice is that the tail is starting to wag the dog. The NHS is starting to fund it and tell it how to provide care, which is completely against the way that the hospice movement was set up. That relates to some of my concerns about the topic that we are debating.
I, like many other hon. Members, have been contacted by Dr. Phil Hyde of BASICS. I am due to meet him in the next few weeks. I have also been contacted by other groups, such as the Sussex and Surrey immediate medical care scheme, and by Dr. Alan Jones at Mid-Anglia General Practitioner Accident Service—another excellent voluntary organisation. One of the most telling things that the hon. Member for Winchester mentioned was the figure of 750 responses to 1,200 requests. That is a fantastic response for a voluntary organisation; but as a former member of the emergency services who has attended road traffic accidents while we waited for response units, I know that it is a frightening experience for the patient and the other emergency services when they do not know who is coming and whether there will be a response. As the hon. Member for Romsey (Sandra Gidley) said, that is not new.
I have been out of the fire service for some 17 years, but in the 11 years that I was in it, I never once trained alongside an ambulance paramedic crew. We do not train together. What goes on out there is frightening. When people arrive at an incident, the training clicks in, but very often it is individual training. I was out recently with a crew from the London ambulance service, and I asked them when they last trained with other emergency services—the police or particularly the fire brigade, with whom they would go to RTAs. The gentleman I spoke to had served 20 years, and he had not trained in that way. I asked my own local fire crew, green watch at
Hemel fire station, which is a joint station with the ambulance trust, “When was the last time you trained with ambulance paramedics?” and was told, “We don’t sir; we ask but it does not happen.” The pressure of time, particularly on the ambulance service and paramedics, is crucial.
An aspect that we need to examine, which has been alluded to in the debate, is best practice, if that is what we want to call it, and the lack of a defined system throughout the country. I, like the hon. Member for Romsey, do not like using the term “postcode lottery” for the pot luck situation in which where people live affects the emergency services that they may need to use, but I do not know a better way to describe it. People in one PCT are likely to get better care than people in others. I, too, have been to Sunderland and Newcastle, where they have a wonderful system, but I have also been to other parts of the country where things are much more difficult.
It is best to listen to the experts as well as to politicians. A recent report by the Royal College of Surgeons shows that a third of all deaths from trauma are avoidable. That is in the 21st century NHS, with £110 billion going into it, and the vast majority of those cases involve people under the age of 44. The largest cause of death of people under 44 in this country is trauma—road traffic accidents. Our lifestyles mean that those incidents will occur. So, surely, we should have a level playing field across the country for the care and expertise to be provided by the emergency services when they arrive.
I have also read reports that say that consultants are needed to lead trauma teams at as many incidents as possible. The problem is that, as many hon. Members know, we have a shortage of consultants, particularly accident and emergency consultants, and as those pressures mount, it is very difficult for any PCT or acute trust to decide to take a consultant out of A and E and send them to an incident. I should very much like to discuss during this debate how we could increase paramedics’ skills. I fully admit that in the past decade the skills of our paramedics, who serve us wonderfully well, have hugely increased.
I was a paramedic in Her Majesty’s armed forces many years ago. A paramedic means something completely different in the armed forces. I left the Army in 1982, with three years’ training as a paramedic for use on the streets of Northern Ireland, where we dealt with huge problems, with airways in particular. We were trained in tracheotomy. The most basic Army paramedic had done a tracheotomy course before being deployed with troops. When I left the armed forces and joined the Essex county fire and rescue service, I was asked to take a first aid course: I had three years’ paramedic training. I would love to say that things have changed and that we have better paramedical or even first aid skills in our emergency, particularly fire, services. In some parts of the country that is true, but mostly it is not.
Will the Minister think about the skills base of our armed forces? We learned this weekend that three of our brave Paras from the 2nd Battalion the Parachute Regiment, had died on active service in Afghanistan. However, many members of our armed forces who are injured on active service survive injuries that they would not have survived 10 or 20 years ago. Is it a consultant from accident and emergency who attends them in the field when they have been blown to smithereens or a
consultant A and E surgeon who treats them when they have been shot while in the field? No. It is a paramedic: highly skilled paramedics who understand and can do the work there and then, at the incident, to keep someone alive long enough to enable the experts to get hold of them.
We have made enormous progress with the skills of paramedics and with air ambulances throughout the country, but that is sporadic, with respect to skills and qualifications. That is something that we can consider, because we need to think carefully about how money is spent in the NHS. As well as using the extra skills of the volunteers who have been mentioned—many of whom tell me, interestingly, that they have retired from the NHS and keep their hand in by using such skills—I should like to examine the skills base of our paramedics.
We have heard about the ambulance service this morning. It was a great honour for me to be asked to be a trustee of the new Herts air ambulance service—a completely charitable organisation, which was set up because Essex air ambulance was covering Hertfordshire as a charitable organisation. That is fundamentally wrong: the Essex air ambulance was in Hertfordshire, and was not giving cover to the people who had raised funds for it, so we worked together on the situation.
Alongside my hon. Friend the Member for Welwyn Hatfield (Grant Shapps), I sat in on some of the meetings with the PCT, ambulance trust and other bodies, and I could not believe how difficult it was to agree what sort of ambulance we should have. Should it have a paramedic on board, and who would pay for that? Should it have a consultant? Should it have a trauma team? Should it be just a lift helicopter, which goes straight to the incident and, once the patient has been stabilised, is up and away to the nearest major trauma unit?
I praise the Government for initiating major trauma units. The Minister knows that I am concerned about accident and emergency and acute services being penalised, because of money going elsewhere. A and E departments are closing, not least in my constituency. However, I could not believe the lack of willingness at the meetings that I attended to say, “This is a voluntary organisation, raising money to help local people, so let us sit down and help them, rather than come up with lots of reasons why what they propose should not happen.” I understand from other air ambulance trusts around the country that that is not new. The availability of ambulances is a completely ad hoc situation.
I was astonished by what the hon. Member for Winchester said about helipads. We had a short conversation about it before we came into the Chamber. To use another military example, it is possible to put a helipad down nigh on anywhere in an emergency, if necessary. Two people—one person—can lay a helipad and make sure that the windsock goes up, the helipad markers are down and there is a certain amount of space.
Frankly, it is ridiculous in the 21st century that someone who is so seriously injured that they need to be casevac’d by helicopter should be put back in an ambulance to be driven to the A and E department. I hope that the Minister will look into that and give assurances to the Chamber that, if it is taking place, it will be stopped. It cannot be what our constituents deserve. We must consider how our communities can work together better for our
constituents—whether the voluntary sector, PCTs, which in some areas are under extreme financial pressure, or acute trusts, which are also under pressure financially and because they are trying to centralise services. With something so serious, Ministers must get away from saying, here in London, “This is nothing to do with us. It is a matter for PCTs and localisation.”
The other day, I asked a very simple parliamentary question about which services should be available at a hospital advertising an A and E department—not a minor injury unit, a surgery centre or a polyclinic. Driving around my town, like most of my constituents, one will see signs for the hospital with “A&E” written underneath. In response, I was told that it is matter for local PCTs. That should not be the case for a question as acute as which hospital someone is taken to when critically ill. There must be a set plan for what is available throughout the country when dealing with major trauma. In my case, I took my daughter to the A and E department at my local hospital, only to be told that it could not take her, because it does not do paediatrics and has no children’s facilities. Naturally, because she was very ill, it said that it would look after her as best it could and then move her to the Watford hospital.
The least that our constituents deserve is for the Government to set out centrally a basic template of what services should be available throughout England and Wales—I realise that such responsibility is devolved in Scotland—so that all of us, no matter where we live in the country, get the best possible provision that the NHS can provide.
10.33 am
The Minister of State, Department of Health (Mr. Ben Bradshaw): I congratulate the hon. Member for Winchester (Mr. Oaten) on raising the important question of how the NHS deals with trauma, which is an issue of interest to many hon. Members. I also welcome the valuable work of all those who work within the British Association for Immediate Care, to whom I am sure that all hon. Members present are deeply grateful. I am also sure that all hon. Members share my desire to see NHS services deal effectively with severely injured patients, and to give them the support and treatment that they need. I agree that trauma care is a serious issue on which the NHS has not performed as well as it might have done in the past.
The issue is about not only how best the NHS can deal with seriously injured patients, but who is best placed to make detailed decisions on staffing and the organisation of services. These debates often tease out the tension between the desire to devolve more powers and decision making to local and regional levels, which all political parties represented here are signed up to, and the need to explore whether there should be a stronger national framework—again, that has been well illustrated in this debate.
The Government believe that, as the hon. Member for Hemel Hempstead (Mike Penning) just suggested, we should give strategic direction—a national framework, if hon. Members like—to public services. However, in the end, it is for local and regional health bodies to determine the best organisational arrangements to ensure that the right people are in the right place at the right time to look after patients appropriately.
Mike Penning: I agree that the basic infrastructure for deciding where people should be taken must be a matter for local authorities. However, the question of what type of care is available must be for central Government diktat, otherwise we will continue the postcode lottery that affects the NHS today.
Mr. Bradshaw: The idea that the decision on what is available, and where, should be for central Government diktat is very interesting coming from the hon. Gentleman, and I might bring it up in future debates, if he is suggesting that we are being too dirigiste. However, I shall elaborate on my arguments in a moment.
The hon. Member for Winchester has rightly pointed to last year’s report on trauma care from the National Confidential Enquiry into Patient Outcome and Death, which stated that every year between 3,000 and 4,000 severely injured people are admitted to hospital in the UK, so the majority of hospitals see fewer than one severely injured patient per week. The report found that hospitals that saw more patients had better outcomes, as they were more used to dealing with challenging cases. The NCEPOD report recommended the establishment of regional, specialist units and the development of protocols to ensure, for example, that ambulances take patients to the most suitable centre, bypassing others that are nearer, where it makes clinical sense. It also made recommendations on the care that should be available to patients before arrival at hospital. When it was published, the Government welcomed that report, and we will take forward its recommendations.
The NHS is already improving services provided by ambulance staff at the scene of such incidents and accidents. As the hon. Member for Hemel Hempstead has rightly pointed out, there is an interesting contrast between the improved performance of the military medical services, in the field abroad, where we have seen dramatic improvements in survival and recovery rates among armed service personnel after severe injury, which has not been replicated in civilian trauma treatment. We are very keen to learn the lessons from that. He was also absolutely right to stress the important role of paramedics, who, I am informed, already do a lot of work in unblocking windpipes, for example, which I think that he acknowledged. There could be an issue about the delivery of anaesthetics, which might require doctors being called in from elsewhere. However, we are certainly keen to learn as much as we can from the experience of the armed services, and I have already asked my officials to look into that.
Mike Penning: I am sure that the Minister realises that many of those skilled military medics are actually NHS employees and members of the Territorial Army, who do a fantastic job for our armed forces when they deploy with their TA units.
Mr. Bradshaw: Absolutely. However, it is also important, when we talk about the respective experiences of the armed forces and the civilian health service—this touches on a point that the hon. Gentleman has raised about rules and regulations for the use of helicopters—to acknowledge that different health and safety parameters can apply to armed forces and civilian services.
Mr. Oaten:
The Army point is interesting. I am not an expert, but my understanding is that NHS consultants who work in accident and emergency departments often
work in Afghanistan or Iraq. Perhaps one of the reasons for the improvements relates to the lesson about BASICS. It may be not the trained paramedics, but the consultants working in the field who are making the difference.
Mr. Bradshaw: We are drifting away from the subject of the debate into another important area. We are acutely aware of the benefits of the cross-fertilisation of experience between the NHS and the military health services. In fact, the Government recently published a paper asking all trusts to encourage their staff to join the TA and to gain experience in the field. The hon. Gentleman is right—the more experience that staff can gain, the better.
The other very important development under way is the next-stage review, under the auspices of my noble Friend, Lord Darzi, who published his report on the future of health services in London about a year ago. I am sure that hon. Members who are acquainted with that report will acknowledge that it recommended the acceleration of improvements for a range of care, including trauma care. The Government support that proposal and expect the London PCTs to agree their forward programme on it tomorrow.
As part of Lord Darzi’s national next-stage review, we have been holding working groups of local clinicians and others in all England’s other strategic health authorities to consider clinical evidence across all areas of health care, including trauma. Those groups have identified what they believe to be the best models of trauma care for patients. Each SHA has now published its vision for the future of health care in its region, based on the recommendations of those working groups. Those visions include improvements to services for seriously injured patients, for example, through the development of specialised centres for the treatment of major trauma to improve outcomes for patients and save lives.
I was interested to read the response, which inspired this debate, from BASICS to last year’s NCEPOD report. It states:
“The public, patients, politicians, managers and the professions need to understand that better outcomes in major trauma are more likely in units staffed by personnel undertaking sufficient throughput and with all relevant specialties to hand. Of necessity this mandates greater regionalisation of services and patients travelling that little bit further to hospital.”
I suggest that that presents a challenge to all politicians who regularly come under pressure from political campaigns to fight to preserve every service that is provided in every local general hospital. It is quite clear from the evidence, which has been widely acknowledged in the debate, that a move to more regional trauma centres will save lives. I hope that when we have such controversies in future, the hon. Members who have spoken today will support their local and regional health bodies and the Government, when we make such a case.
Mr. Oaten: I am happy to set an example and say that I am comfortable with making the case to my constituents in Winchester that some things should happen not at Winchester hospital but in Southampton. If I had an accident, I would much rather go to Southampton. Surely the point is that if I am going to a specialist centre, I want to get there quickly. I am all for specialist centres, but only if people can get there quickly.
Mr. Bradshaw: I hope that hon. Members who are facing re-election at the next election are prepared to display similar courage when it comes to the reorganisation of health services in their local area. [Interruption.]
Dr. McCrea (in the Chair): Order. I would appreciate it if whoever is responsible would stop their mobile phone ringing.
Mr. Bradshaw: I want to update the hon. Member for Winchester and other hon. Members present, most of whom represent constituencies in the South Central strategic health authority area, about the most recent developments there. The SHA informs me that trauma cases in its area are handled by nine acute trusts that have a major A and E department and are classified as receiving hospitals in the event of a major incident. Casualties are triaged and assessed on the scene before being taken to the most appropriate hospital to treat their injuries according to the clinical judgment of paramedics and, if needed, BASICS doctors. They are taken either by ambulance or by air ambulance. If required, BASICS volunteers are activated by the ambulance service for the treatment of casualties on scene, and acute trusts have the ability to activate their own doctors and nurses to form a mobile medical team to assist with the provision of pre-hospital care.
I turn to the hon. Gentleman’s point, which has been repeated in the media, about a consultant in A and E who was a volunteer being told that they could not go to the scene of an incident. I do not know whether that example is hypothetical or real, but it has been raised before. The national clinical director for emergency access, Sir George Alberti, of whom many hon. Members may have heard, is looking into whether there may be merit in the Department’s appointing a specialist trauma tsar to help to drive the national network. The danger is that if we appoint too many tsars, we will reduce their value.
Sir George was asked about that particular case recently on Radio 4. He said that that would not be acceptable, and that clinical priorities should always come first. He said that if someone was making an allegation based on a real example, they should provide him with details and he would look into it, but he has not heard anything more. If the hon. Gentleman would like to, he can furnish either me or Sir George with such an example. We have made it quite clear, as should hospitals, that if there is a clinical need for somebody to go out to the scene of an accident, that should happen—South Central SHA has told me that. Such a person should not be held back in A and E because they are on duty there or because of the desire to hit a target. I wished to put that on record for the hon. Gentleman.
The hon. Gentleman asked whether I have received a request to meet NCEPOD. I have not received such a request, but I have asked to meet NCEPOD about a different matter that came up in the past two weeks, so I am sure that we shall take the opportunity of discussing this matter. As he has acknowledged, NCEPOD has regular meetings with my officials, and its input has been important in helping us to draw up the proposals that we shall publish shortly when Ara Darzi publishes his full next-stage review.
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