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Sandra Gidley (Romsey) (LD):
I welcome this debate. When I first read the Conservative motion, I thought it was a bit of a hotch-potch: half of it nobody could
disagree withit praises everyone under the sun, and there is nothing wrong in thatbut the rest of it seemed like the product of a brainstorm, with references to almost anything that might be remotely related to emergency and urgent care. However, although some of those topics have not been pursued in the debate so far, the Conservatives have highlighted a very important subject.
The hon. Member for South Cambridgeshire (Mr. Lansley) took the Secretary of State to task because the Governments amendment mentions out-of-hours care, but I think the changes in the provision of that care have had an impact on emergency and urgent care, so it is probably worth mentioning some of them. The Government have done many things to improve care for patients, but they would probably acknowledge quietly that one of their biggest mistakes was to take responsibility for out-of-hours care away from GPs and put it in the hands of the primary care trusts. As a result, the GPs were only responsible for the core hours from Monday to Friday. In some areas, GPs wanted to provide weekend care, particularly if they had a high commuter base, but that was actively discouraged by PCTs. The costs shot through the roof, and in some places the out-of-hours services were introduced hurriedlyto describe what was on offer in many areas of the country as an unmitigated disaster is putting it quite mildly. Many people waited more than four hours for a GP to arrive. In my area, we are flying in doctors from various parts of the European Union. A lot of them are German. I have no problem with German doctors; they are all very nice, and people generally had a positive experience. However, those doctors did not understand local services and a number of significant problems arose; if they wanted to section somebody, for example, they did not understand the UK law and procedures governing that decision.
The number of people resorting to calling an ambulance also markedly increased. It is perfectly understandable that a concerned patient might do that if the out-of-hours service is not responding and they are not getting the reassurance they need. We should not criticise patients for doing that.
The Government amendment applauds the increase in GP opening hours. I concede that that may have enhanced choice, but I do not think it has improved access to urgent care because many people are making routine appointments for those extra hours. It is important to consider what urgent care actually is, and it is worth posing a couple of fundamental questions. How does the patient know whether their symptoms are the sign of something seriouswhether they can wait to have them checked out, or if they should be making a fuss about being seen? It is clear that different patients respond in different ways. Most GPs will have their regular complainers, but in the days when GPs knew their patientsI hate to say the good old days, because I am not sure they were good in all respectsthe GP was often able to make a value judgment. They could say, I saw Mrs. X only last week. I know her quite well, and I think reassurance will go a long way in this case. In the hands of a doctor who does not understand Mrs. X, however, more resources might be used because they do not know the background and personality of the patient and they will therefore treat them on a more precautionary basis.
I suspect that most Members present will have been out with an on-duty ambulance crew. From witnessing them calling on people, it is obvious that there is a wide range of differing attitudes as to the circumstances in which it is appropriate to call the ambulance service out. One of my first pieces of casework when elected as an MP related to an ambulance that did not arrive to a call from a rural setting, and I was horrified to find out that ambulance crews were often having to deal with very trivial cases. Although the ambulance service does a wonderful job, it does not need to do much of what it does. Every time somebody with a trivial complaint calls out an ambulance, they are potentially endangering the life of somebody else. That risk is not communicated often enough.
The first point of call for people who are ill is usually the surgery. Even if it is closed, they often think of calling their GP, and, in many cases, the call is diverted to the appropriate out-of-hours service. That is what one would expect, but the recent Healthcare Commission report showed that in a significant number of casesI cannot recall the statistic off the top of my headthe relevant information was not communicated. That resulted in the patient either having to dial somewhere else or thinking that they did not want to speak to a doctor who they did not know and wondering whether they had any other options. Some people will look at various websites for advice, whereas others will go to their nearest pharmacy. Accessing NHS Direct, either on the web or by phone, is a popular choice. Other people will choose to use a walk-in centre or out-of-hours care, or they may call an ambulance because they do not know what to do and are worried.
I welcome the move towards having a single contact number, but I make a plea that during the consultation we examine what has happened when the police and other bodies have introduced such a number. Often, what has happened is that all the other numbers have gradually been withdrawn and people have not then been able to choose to ring the department that they want directly; they have always then had to go through a central switchboard, and often they have not been able to ring their local provider and speak to the person whom they know. To be fair to the police, locally they have got much more sophisticated about this and have found other ways of getting around the system. People who know whom they wish to ring find it frustrating to have to go through a bureaucratic telephone triage serviceto go somewhere else. By all means, let us have a single point of contact, but if someone knows whom they want to contact, it should be easy for them to do sothere should be no barrier. So, there are pluses and minuses to the proposal.
I wish to discuss the strain on ambulance services. As a result of inappropriate calls, the London ambulance service, among others, introduced a clinical telephone advice team to advise callers who had less serious conditionsthe team made a point of ringing such people back. During 2007-08, the London team handled more than 58,000 calls, and analysis showed that, over the year, that freed-up the equivalent of 35,383 ambulances for patients who needed them more. Not every ambulance trust has that sort of system in place, despite facing similar pressures, so it may be worth considering whether that is best practice. Although different areas rightly provide different solutions, it is also worth examining things that work well elsewhere.
This might be an appropriate time briefly to mention ambulance response times. The most commonly known target is to reach 75 per cent. of category A life-threatening situations within eight minutes of the call. I have never been able to establish why eight minutes was decided as the crucial figure or why 75 per cent. is acceptableperhaps the Secretary of State could enlighten mebut there are added pressures this year. In previous years, some ambulance trusts have been accused, rightly or wrongly, of manipulating the time when the clock started in order to improve their results. Now, so that there is no dispute, the clock starts ticking as soon as the call connects and there is thus a level playing field.
Mr. Burns: If the hon. Lady is correct in saying that the clock starts when the call commencespresumably we are talking about the call from the member of the public to the ambulance servicehow can there be a level playing field, given that some people may take three minutes to explain the problem about which they are ringing whereas others may take just half a minute?
Sandra Gidley: I do not think that the people who take three minutes are predominantly to be found in Chelmsford and the people who take half a minute are predominantly to be found in another area of the country; the variation will be found across the country. I do not really understand the point that the hon. Gentleman is making; I think it is a rather trivial one.
Sandra Gidley: No, I will continue with the point that I was intending to raise. Just before Christmas, the pressures to which allusion has been madeI will not repeat themmeant that the London ambulance service had its busiest week in history; ambulance staff responded to 20,939 emergency incidents across the capital in the seven days up to 14 December. That was an increase of 8 per cent. on the average for the previous four weeks. The pressure was intensified by the high percentage of calls that were initially treated as category A situations. There is a growing sense of disquiet in some quarters about that fact that canny members of the public know that if they mention chest pain, an ambulance will be sent very quickly. There is a need for a retrospective review as to whether calls are being categorised correctly. No trust wants to gamble with peoples lives, so perhaps this is the way we have to do things, but the system has been in place for some years and it is probably time to change it.
Just after Christmas, particular problems were encountered in Hampshire. The Southern Daily Echo cited a story of a pensioner who was left waiting 70 minutes for an ambulance when she suffered a suspected broken leg, having slipped on an icy pavement. The temperature was below zero, the lady was 85 years old and, apparently, it did not require a paramedic to see that her leg was broken because it was at a fairly unnatural angle. The South Central ambulance service was unable to provide a comment at the time of the report.
Only two days later, another serious incident took place. A seriously injured policeman had to be rushed to hospital in a fire engine because no ambulance was available. A special equipment unit was transformed into the makeshift ambulance because the patient needed urgent medical treatment following a crash in Southampton. A paramedic had arrived on the scene, as had a BASICSBritish Association for Immediate Caredoctor, but the ambulance response was not forthcoming. There are always times when unusual demand is difficult to cover, but in an emergency a situation such as I have described is of concern.
I wish to discuss BASICS doctors, because they have not been mentioned in this debate and they are an often-forgotten part of the response to major trauma. Dr. Phil Hyde, a constituent of mine, approached me
Sandra Gidley: This could be a debate that we have had in Westminster Hall, but as some hon. Members were not present for that, it is worth repeating things. In addition, some of the points from the Westminster Hall debate were not addressed. If the hon. Gentleman is saying that because we had a debate on Equitable Life, we do not need to discuss it again, that is fine, but I contend that if a subject is important, it is worth discussing on repeated occasions.
Prior to the meeting with my constituent, I had no inkling of the fact that if I were seriously injured in a road accident, my prognosis would be severely affected by whether or not a voluntary doctor was available. Many such doctors work full-time in the NHS, often in disciplines such as anaesthetics and sometimes in emergency care. I had always thought it was like Casualtyonce a year, usually on the Christmas special, there is a major incident and all the casualty doctors go to the scene of the accidentbut, in real life, that is not what happens in most parts of the country. This matter is important because of what is said in the often-overlooked 2007 report by the National Confidential Enquiry into Patient Outcome and Death, entitled Trauma, Who Cares?. It concluded that the current structure of pre-hospital management is insufficient to meet the needs of severely injured patients. There is a high incidence of failed intubation and of people arriving at hospital with a partially or completely obstructed airway. The report continued:
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.
The stark reality is that patients who die from severe injuries often do so within the first hour after an accident, and in the UK that time has usually passed before the patient reaches hospital, and that is on the assumption that the ambulance and paramedic response to the scene is normal. If a BASICS doctor arrives, they can stabilise the patient at the scene of the accident and decide the most appropriate destination for that person. It must be borne in mind that, because of centralisation of services and major trauma centres, the destination is not always the nearest hospital. BASICS doctors therefore provide a benefit in terms of the appropriate care.
During the Westminster Hall debate, the Minister said that he would shortly have a meeting with the people responsible for producing the report from National Confidential Enquiry into Patient Outcome and Death, and that he would raise some of the issues that were mentioned during the debate. It would be useful if he could update us on that. The BASICS service is voluntary and often funds its own equipment because doctors do not have enough time, after doing their full 48 hours in the NHS, to provide the emergency service and carry out fundraising.
Some parts of the country, such as Sunderland, have focused on trauma injuries and significantly reduced the death rate from major trauma from the national average of 5.8 per cent. to 2.9 per cent., and have introduced new response teams, which seem to be having an effect.
Many parts of the country rely on air ambulances, and it is frustrating that the running costs are often funded by local donations and voluntary contributions. I am a little worried about that. Although in my neck of the woods in Hampshire the air ambulance service is relatively new and is given the current financial pressures well supported at the moment, there is concern that funding for all charities may decline. The South Central Ambulance Service NHS Trust told me that it pays for the clinical response, but not for the helicopter, which is funded by a well organised group. That was a strange response, because it does not say that it will provide paramedics but not fund the costs of ordinary ambulances. I am not sure of the significance of different modes of transport. What consideration has the Minister given to charitable funding of air ambulances, and does he believe that that is sustainable in the long term?
Last year, the Healthcare Commissions report, Not just a matter of time, reviewed urgent and emergency care. It concluded that most sectors performed well against national standards for access to services, but it found that performance was more varied in services that receive less national attention. That is no great surprise, and Members of Parliament are always highlighting those services. The overall stats show that the response to category A calls was generally good. That is where the main focus falls, and there is not a lot of room for argument, but one should note that those results are given by trust. I made a freedom of information request to find out the response times on a ward-by- ward basis in my constituency. Lo and behold, those parts of my constituency in Southampton received an 80 or 85 per cent. response, which is excellent for people who live in the big city, but in some of my more rural wards an ambulance had never reached an emergency within eight minutes. That is not something to shout about, because it is inequitableindeed, it is the reverse of the inequality usually seen in the health service, because those who are suffering are not those who live in urban areas, but who perhaps live in more affluent areas. Does the Minister have any plans to refine the targets so that it is realistic to expect an ambulance to reach people within eight minutes, wherever they live, not just in the large urban conurbations?
Mrs. Nadine Dorries (Mid-Bedfordshire) (Con):
Would the hon. Lady be satisfied with an assurance that an
ambulance would try to get to those who need it? It could be trying for hours. Is that the sort of reassurance that she is looking for?
Sandra Gidley: Perhaps my choice of words was unfortunate, but at the moment the response times are based on large geographical areas, so if a 75 per cent. rating is achieved throughout a trust area, the target is reached, but there is no subdivision that provides that targets must be reached in all areas. It is clear that some areas do not receive the service that they should, and I suggest that the hon. Lady makes a freedom of information request to her ambulance trust. I had always suspected that my rural areas received a less than good service, but the results are much worse than I had anticipated, and almost a whole borough council area was missing the target. Surely there is something wrong with such a response time.
Mr. Burns: May I try again on the targets? Despite the look on the hon. Ladys face, I think that she misunderstood my point. She suggested that the eight minutes starts at the moment the call is taken, but if someone is agitated, they may take three minutes to explain why they need an ambulance, and someone who is less agitated or more articulate may take 30 seconds. Surely a target of eight minutes is unfair if the starting time for monitoring purposes is the moment that the call starts. That is all I was trying to say.
Sandra Gidley: The level playing field to which I referred was between trusts. There has been significant variation in the way in which response times were monitored. For example, some started the clock when a call first came into the centre, others started it when the call was answered, and so on. I understand the hon. Gentlemans point, but if trusts are given flexibility to make a value decision on how to obtain the correct information, that is open to manipulation. All the evidence that I have seen shows that trusts consider every step of the pathway to try to make their figures look better and to hit the target. I do not blame them, because if they achieve their target, they are not subject to greater scrutiny, but there is not a quick, easy and simple way of taking that measurement out of the system and retaining equity in the way in which response times are compared with other trusts. I sympathise with the hon. Gentlemans point, but there is no quick and easy answer.
Sandra Gidley: If the hon. Gentleman does have a quick and easy answer, it is probably not appropriate for an intervention. He might want to stand up and make some comments later, but I feel that I should finish my speech so that other hon. Members can speak.
The response to category A calls is good, but there is much more variation between the targets and the responses in the case of other urgent calls. The Healthcare Commission found that in some areas fewer than 80 per cent. of ambulances arrive within the target time. On arrival in hospital, there are significant variations in the proportion of patients seen by a doctor or nurse within the first hour after arrival. That figure varied from 40 to 100 per cent. Clearly, there is work to be done.
There is also evidence of poor compliance with guidance on access to medication from out-of-hours GP services. Although that might not be seen as urgent care, if a patient is in pain or something like that, the care is certainly urgent to them. Concerns were also raised that suggested that many people were either unaware of the full range of urgent and emergency care services or were unsure about how and when to use them, which brings us back to the issue of the single contact number. Most importantly, the need to improve the way in which the services work together was highlighted.
Data-sharing is poor and PCT commissioning was highlighted as a concern. A survey produced last week showed that patients rate their care highly but raise concerns about pain control and information given on discharge. That takes us back to the mention of data sharing in the earlier reports. The people who are providing emergency care often do not have sufficient information about the patient. If somebody has been in accident and emergency, or has even been treated in out-of-hours care services, the relevant information is not always relayed back to the GP in as timely a fashion as it could be. Perhaps the Minister could tell us when decisions will be made about information-sharing with regard to the NHS IT project. There is a lot of healthy debate about what level of information can be accessed by whom, but it could be crucial to outcomes in those particular cases.
I want to end by making a comment that many hon. Members start their speeches with: I thank those who do their best to provide an emergency service, whether they are paid workers or volunteers such as community first responders or BASICS doctors. We owe it to all those people to ensure that attention is given to ensuring that people have the best possible outcome in the case of emergencies and that the PCTs ensure that funding streams are adequate. The problem with this area of medicine is that most people are grateful to have received urgent care, and they are often so pleased to be better and to have their problems sorted that they do not take the time to step back and ask whether their outcome could have been improved or whether their quality of life could have been different had a doctor been on the scene. Staff want to do better, but in many cases they are hampered by a lack of attention to best practice and, in some cases, sadly, by a lack of funding.
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