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My noble friend Lord Judd, supported by the noble Lord, Lord Chorley, have tabled amendments which would include the national parks as representatives in

23 Mar 2009 : Column 514

every region in which there is a park and necessitate consultation with them. We want the leaders’ boards to be small enough to be effective, streamlined, managed and properly representative of local areas, but the noble Lords have made an important case. On Amendment 160, I recognise the importance of my noble friend’s argument regarding the national parks. I have listened to the concerns expressed and we will come back with a proposal to ensure that the Bill enables national parks to be properly represented without undermining the principle of regional self-organisation.

On my noble friend’s Amendment 165, on the consultation arrangements, it is clear to me that noble Lords consider it important to spell out in more detail the relationship between the responsible regional authorities and the local authorities boards and individual local authorities. Again, I am willing to take the matter away and consider how we can address noble Lords’ concerns by setting out more clearly in the Bill the reciprocal duties of the responsible regional authorities to consult, engage and take advice from local authorities in the region and the responsibilities of local authorities to engage in that process. I hope that noble Lords will be happy about that.

On the amendments laid out by the noble Lord, Lord Hanningfield, I think that we had a similar group of amendments in Committee. Amendments 157 and 164 require the responsible regional authorities to seek advice from the county and unitary councils, the national parks and broads authorities, and so forth. The noble Lord makes a powerful case about the different geographies of this country, in particular the rural as opposed to the urban. This is a restatement of amendments we considered in Committee, particularly in the light of concern expressed by the Local Government Association that the Bill does not replicate the Section 4(4) provision of the Planning and Compulsory Purchase Act 2004 and is therefore perceived as weakening the role of strategic authorities held in principle under the previous legislation.

I sought to reassure noble Lords and the LGA that counties and national park authorities will have a number of clear statutory roles. I subsequently wrote to the LGA and the ENPAA setting these out. They include different levels of responsibility; a new duty to prepare economic assessments, which will be a key input, as we have just described, into the evidence base of the regional strategies; and a crucial role in establishing and configuring the leaders’ board in their region. Many county leaders will be members of their leaders’ board and therefore have direct management control of the regional strategy and process. They will also have a role as statutory consultees in their own right and be consulted on draft revisions to the regional strategy. We will set out our consultation expectations in regulations and guidance, including a list of consultees. That will additionally be covered in the statement of community involvement.

I believe that this package of provisions give counties and national parks much more real, practical influence over the regional strategy than they had over the RSS via the regional assembly, which had a much looser arrangement, and certainly more than they ever had in relation to the regional economic strategy. We have a

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range of ways in which counties and districts can take advantage of input and participation to get a better level of influence. I think it will be a challenge and although I agree that we have not replicated it in exactly the same way as in the PCPA, there will no loss of opportunity or access to influence.

I turn briefly to Amendment 168 in the name of my noble friend Lord Judd and the noble Lord, Lord Chorley. We will shortly be debating the need for an integrated strategy and I know that this amendment will keep the current system of regional spatial strategies by retaining Part 1 of the 2004 Act. I will not rehearse my arguments now but will say that we urgently need a single strategy to bring together the spatial expression of the need not least to provide more housing but also to manage our resources, with the economic strategy which is more closely focused on economic considerations such as jobs, skills, enterprise, business, investment and innovation. That is what a single regional strategy will do for the first time. It is long overdue in some cases. However, if noble Lords will allow me, I will come on to that debate later.

7.15 pm

I turn to the three amendments in the name of the Liberal Democrat spokesmen. Amendment 160A would allow local authorities to choose to opt out of participation. I heard what the noble Lord, Lord Tope, said, but I did not find it very convincing. We have already made clear the flexibility available to participating authorities in determining how they establish their leaders’ board and who should be a member, and I think that that is right and proper. Given the importance of the strategy and the key role of the leaders’ board, it seems right to require at least a certain level of participation from every local authority in critical parts of that process, and I think that input to establishing a leaders’ board is one of those.

Amendment 160B is about participation and representation by all political parties. I think that that was very well answered by my noble friend and I do not have anything to add to that. Finally, Amendment 164A puts a greater onus on the statement of community involvement to demonstrate that the policies within the statement will be effective. I do not think that the amendment has that effect. We had a discussion in Committee about the challenge of making community involvement a genuine and inclusive process. It is very important that we work hard to make that so, and we committed to doing it. Looking at this amendment, it is very difficult to define effectiveness and very difficult to define how it might be assessed. I am sure that the noble Lords would not want a purely presentational amendment; they would want it to work, and there is already an implicit expectation that policies put forward by the responsible regional authorities should be effective. If they are not, they will certainly be challenged in the iterative process of consultation, in the examination in public.

I regret that I cannot accept these thoughtful amendments. However, I hope that noble Lords have been persuaded and that my noble friend Lord Judd is happy that we will address the issue that he raised in his amendments.

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Lord Hanningfield: My Lords, I thank the noble Baroness for that very comprehensive answer. I do not think that it totally addresses the points that I made at the beginning. If the economic assessments are going to be carried out by counties in conjunction with districts—we did not win the concession that they should be automatically involved, but we are assured they will be—then when it comes to the actual regional strategy, since the bodies we have just been talking about are not going to be properly, statutorily consulted on it, I do not see how the thing is going to be joined-up. I do not accept what the noble Baroness said about the regional strategy being joined-up and from the bottom up.

The noble Lord, Lord Smith, made a convincing argument about what was happening in the north-west but he was actually talking about how the leaders’ board would operate. The ultimate power will be the regional development assembly—that is my point as well as the point of the noble Lord, Lord Judd—and my amendment would make the national parks a consultee in the regional strategy. This is an LGA amendment. It is an all-party amendment from the LGA and I do not see why the Government cannot accept it. It would put into the Bill what should happen and who should be consulted about establishing a regional strategy. It is very important to test the opinion of the House on this.

7.19 pm

Division on Amendment 157B

Contents 92; Not-Contents 118.

Amendment 157B disagreed.

Division No. 2


Addington, L.
Anelay of St Johns, B. [Teller]
Astor, V.
Attlee, E.
Best, L.
Bew, L.
Bonham-Carter of Yarnbury, B.
Brooke of Sutton Mandeville, L.
Brougham and Vaux, L.
Byford, B.
Carnegy of Lour, B.
Chidgey, L.
Colwyn, L.
Cope of Berkeley, L.
Cotter, L.
Craigavon, V.
Dholakia, L.
Dixon-Smith, L.
Dykes, L.
Eccles of Moulton, B.
Falkland, V.
Falkner of Margravine, B.
Fearn, L.
Fowler, L.
Garden of Frognal, B.
Gardner of Parkes, B.
Geddes, L.
Glasgow, E.
Glentoran, L.
Hamilton of Epsom, L.
Hamwee, B.
Hanningfield, L.
Harris of Richmond, B.
Hooper, B.
Howe, E.
Howe of Aberavon, L.
Howe of Idlicote, B.
Jenkin of Roding, L.
Kirkwood of Kirkhope, L.
Knight of Collingtree, B.
Lee of Trafford, L.
Lindsay, E.
Livsey of Talgarth, L.
Luke, L.
McNally, L.
Maddock, B.
Mar and Kellie, E.
Marlesford, L.
Masham of Ilton, B.
Mawson, L.
Mayhew of Twysden, L.
Neuberger, B.
Neville-Jones, B.
Northbrook, L.
Northesk, E.
Northover, B.
O'Cathain, B.
Onslow, E.

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Pearson of Rannoch, L.
Razzall, L.
Redesdale, L.
Rennard, L.
Roberts of Llandudno, L.
Rogan, L.
Rotherwick, L.
Rowe-Beddoe, L.
St. John of Bletso, L.
Scott of Needham Market, B.
Seccombe, B.
Selborne, E.
Sharp of Guildford, B.
Shrewsbury, E.
Shutt of Greetland, L.
Skelmersdale, L.
Smith of Clifton, L.
Steel of Aikwood, L.
Stoddart of Swindon, L.
Strathclyde, L.
Taylor of Holbeach, L.
Teverson, L.
Thomas of Gresford, L.
Thomas of Winchester, B.
Tonge, B.
Tope, L. [Teller]
Tordoff, L.
Ullswater, V.
Vallance of Tummel, L.
Verma, B.
Waddington, L.
Wallace of Saltaire, L.
Walmsley, B.
Walpole, L.


Acton, L.
Adams of Craigielea, B.
Adonis, L.
Alli, L.
Andrews, B.
Archer of Sandwell, L.
Bach, L.
Bassam of Brighton, L. [Teller]
Berkeley, L.
Bernstein of Craigweil, L.
Bilston, L.
Blood, B.
Borrie, L.
Bradley, L.
Brennan, L.
Brett, L.
Brooke of Alverthorpe, L.
Brookman, L.
Carter of Coles, L.
Chandos, V.
Clarke of Hampstead, L.
Clinton-Davis, L.
Corbett of Castle Vale, L.
Crawley, B.
Davies of Abersoch, L.
Davies of Coity, L.
Davies of Oldham, L. [Teller]
Desai, L.
Dixon, L.
Donoughue, L.
D'Souza, B.
Dubs, L.
Elder, L.
Elystan-Morgan, L.
Evans of Parkside, L.
Falconer of Thoroton, L.
Farrington of Ribbleton, B.
Faulkner of Worcester, L.
Foster of Bishop Auckland, L.
Gale, B.
Gibson of Market Rasen, B.
Golding, B.
Graham of Edmonton, L.
Harris of Haringey, L.
Hart of Chilton, L.
Haskel, L.
Haworth, L.
Henig, B.
Hilton of Eggardon, B.
Hollick, L.
Hollis of Heigham, B.
Howarth of Breckland, B.
Howarth of Newport, L.
Howells of St. Davids, B.
Hoyle, L.
Hughes of Woodside, L.
Hunt of Kings Heath, L.
Jay of Paddington, B.
Jones, L.
Jones of Whitchurch, B.
Jordan, L.
King of West Bromwich, L.
Kirkhill, L.
Layard, L.
Lea of Crondall, L.
Leitch, L.
Levy, L.
Lofthouse of Pontefract, L.
McDonagh, B.
Macdonald of Tradeston, L.
McIntosh of Haringey, L.
McIntosh of Hudnall, B.
Mackenzie of Framwellgate, L.
McKenzie of Luton, L.
Maxton, L.
Meacher, B.
Mitchell, L.
Morgan, L.
Morgan of Drefelin, B.
Morris of Handsworth, L.
Morris of Manchester, L.
Morris of Yardley, B.
O'Neill of Clackmannan, L.
Patel of Blackburn, L.
Patel of Bradford, L.
Pendry, L.
Pitkeathley, B.
Plant of Highfield, L.
Puttnam, L.
Quin, B.
Radice, L.
Rendell of Babergh, B.
Rooker, L.
Rosser, L.
Rowlands, L.
Royall of Blaisdon, B.
Sawyer, L.
Scotland of Asthal, B.
Sewel, L.
Simon, V.
Smith of Finsbury, L.
Smith of Leigh, L.
Snape, L.
Soley, L.
Stone of Blackheath, L.
Symons of Vernham Dean, B.
Taylor of Bolton, B.
Thornton, B.
Tunnicliffe, L.
Wall of New Barnet, B.
Warner, L.
Warwick of Undercliffe, B.
Watson of Invergowrie, L.

23 Mar 2009 : Column 518

West of Spithead, L.
Whitaker, B.
Whitty, L.
Wilkins, B.
Young of Norwood Green, L.

Consideration on Report adjourned until not before 8.30 pm.

NHS: Doctors

Question for Short Debate

7.30 pm

Tabled By Viscount Falkland

Viscount Falkland: My Lords, I think that we shall, unhappily, be a reduced number in a few seconds. I shall try to explain to the House why my debate probably has a small number of people who will be contributing, but to whom I am enormously grateful. I knew very little about this subject until a few months ago, so I can understand people’s bemusement when they read on the Order Paper what we are debating.

My question is whether the National Health Service is actually fulfilling its remit to provide the best possible service at point of need. We all recognise, of course, how it does that to the best of its abilities and within great financial constraints. Yet we are deficient in one area, because what I am about to describe does not exist in most of the countries of Europe or, indeed, other countries in the civilised world. Those who are taken ill or involved in a serious accident outside the London area—that is, roughly within the M25—are treated by dedicated emergency crews that consist largely of paramedics and the police, with ambulances present. Yet there is no doctor present who can cope with critical care for someone who has been involved in a serious motor or sporting accident, or one that involves crushing of the spine or head injuries. Outside the London area, there is no critical care doctor present to make sure that those injured people can get to the appropriate hospital within the time that may save their lives.

In fact, figures tell us that in the south central area—the area on which I have been briefed, through my long friendship with people in the Hampshire Police Authority—for those patients who are seriously injured in accidents of the kind that I have described, there is a 40 per cent mortality rate because of the delays in getting them to a hospital that can deal with them quickly, and with specialist care, within the time. That is because of the paramedics. I would not dare suggest that the paramedics do not do their job admirably; they are dedicated people, underpaid for what they do—with no bonuses whether they do it right or wrong—who go out in all weathers. Up to the level of their competence and training, they do the best that they can. Yet people who are severely injured—who may well be unconscious, have crushed chests with

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damaged airways, or the head injuries about which one reads of so often in the newspapers—need expert attention very quickly.

I have been briefed for this debate by a group of doctors who do not get paid for what they do, but work under charitable funding through an organisation called the British Association for Immediate Care—a sort of umbrella charity. If such doctors volunteer, when they are available and can get out there, people have a chance of surviving. The losses in the southern central area, the one about which I know most through my briefing, indicate what prevails throughout the British Isles. A properly organised, doctor-led service could certainly save 141 lives a year in the southern area; in money terms, I believe that that is roughly calculated as saving the area £186 million a year.

Birmingham, for example, suffers the same in that there are innumerable accidents in that conurbation. In last year’s records, it had 389 call-outs for specialist doctors and 1,978 arrivals. Compared with other parts of the country, that is quite a good record. Yet the number of people in need of the special care of qualified doctors who have to act immediately to get patients to a hospital that can deal with their particular trauma is certainly evidence of a need to overhaul the service. That will entail a National Health Service commitment for funding. My noble friend Lady Tonge is much better qualified than I to talk on these subjects. This comes as less of a surprise to her, with her medical training, than it might to others. She will elaborate in more detail on these matters.

The competence of paramedics is not in question, but when it comes to anaesthetics or opening airways or things that need particular expertise and time, a doctor really is required in quick order—if it is possible to get them there. Once there, those doctors can speed up the process of getting the patient to the right hospital. The job of the paramedics is to get the patient to the nearest general hospital, from where they may then have to be transferred again. It might take as long as 12, 13 or 14 hours before someone with serious head injuries gets to a place where they can be treated, by which time they may be so injured that they are no longer able to function, or they may be dead.

That is the sum of my introduction to this debate, and I do not think that many paramedics would disagree with it. There is nothing that they would like better than to have a qualified doctor working alongside them, but should charitable organisations really be funding those doctors? They can only free themselves when they are not working in their daily jobs but, when they are called, they go out in all weathers and do an admirable job. Is it not time, then, for us to follow the rest of Europe, and the world, in providing a properly funded and doctor-led critical care service? Why should people who are not in hospital but are on their way to it get worse treatment than those who go to hospital and are treated in the normal way?

7.38 pm

Baroness Masham of Ilton: My Lords, I thank the noble Viscount for this Question, which will have made several people think, “What happens outside

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London when patients are critically injured and ill?”. The Minister and I have both been involved with the Red Cross. We know how important emergency medical services are. One Red Cross activity is planning and helping in disasters. More and more paramedics are being used in emergency situations these days. They are now much better trained than a few years ago, and can use much more sophisticated equipment. Regarding an emergency response, however, although paramedics have good assessing skills, they do not always have the competence to prioritise certain treatments. If a doctor could be present, it might be possible to start urgent treatment early, which might reduce serious injury or loss of life.

In TV programmes such as “Casualty”, crash teams with doctors go out to serious incidents. Is that realistic or does it not happen? Perhaps the Minister can let me know whether they give a real or a false impression.

When not in London, my home is in north Yorkshire. The North Yorkshire and York Primary Care Trust is the size of Belgium. It covers 3,200 square miles, much of which is rural. For people living in the Yorkshire Dales, their nearest hospital can be 30 or 40 miles away. Without the air ambulance service, many lives would be lost. Some local GPs are trained to be part of the pre-hospital care team. In this country, all doctors are initially trained by the National Health Service. This important service would not exist without much fundraising.

Seriously injured people are taken to the most appropriate hospital, which may be a long way from home as it is vital to get specialist treatment when the condition needs it. I say to the noble Viscount that some paramedics now carry out this task. They have been trained to take a patient to the nearest specialised hospital. That has recently happened.

The principle of a doctor/paramedic team was first used by the London Helicopter Emergency Medical Service. This fundamental break from the usual paramedic-only model radically changed the dynamics of the crew and the level of care available to patients in the pre-hospital environment. In 2003, the Great North Air Ambulance Service integrated physicians into its team. Several air ambulance services are utilising this approach to pre-hospital care, including in Kent, Surrey, Sussex, the east of England and the West Midlands.

HEMS physicians may originate from a number of specialities, including emergency medicine, anaesthetics and general medicine. Regardless of specialist medical background, doctors should have a strong grasp of the fundamentals and demonstrate practical ability in the other acute specialities. For example, an anaesthetics specialist should have completed a significant period of emergency medicine, and an emergency physician should have a background in anaesthesia and critical care. To this end, most HEMS operations require similar criteria.

Serious illness often presents out of doctors’ hours. It can be very difficult in rural areas for seriously disabled people and people who do not drive to get access to a doctor. Doctors have to cover events such as horse shows, race meetings, rugby games and all sorts of occasions. Organisers of the events have to pay for that, but it shows the importance of doctors being present where there are risks. I think the answer

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to the noble Viscount’s Question is that there is an important need for doctors to save lives, but the NHS cannot afford to do everything. At times there has to be shared co-operation, communication and co-ordination.

Some years ago, a GP called Dr Easton living near Catterick started a rota of GPs linked up with the police, who went out to serious injuries on the notorious A1 and surrounding roads. This excellent scheme was highly commended and appreciated by the local people, but it was in the days when doctors’ hours were more flexible. I hope that strategic health authorities and PCTs across the country will look very carefully at what happens in their locations to critically injured and ill patients and how improvements can be made across the country.

I am reminded of the tragic young rugby player who broke his neck and was paralysed from the neck down. Finally, he went to Switzerland to end his life, which he found intolerable. His mother recently stated that when he was taken from the rugby field to a hospital, his arms were still moving. After having been x-rayed, and twisted and turned, he became totally paralysed. I am told that he should have been operated on within four hours to relieve the pressure on the spinal cord. It was too late by the time he was admitted to a spinal unit.

I end by quoting from the 2007 report Trauma: Who Cares? It states:

“To be effective all processes, including”—

acute trauma life support—

When critically injured patients are being handled and treated, it should be of the utmost importance in the minds of the medical personnel that further damage must not take place and the correct procedures must always be followed.

7.47 pm

Baroness Tonge: My Lords, I congratulate my noble friend on securing the debate. This is an important subject. I must confess that the more I look into it, the more amazed I am at how inadequate the provision is. In the 10 years since I stopped practising in the health service, I had not really thought about it. It really is quite astonishing.

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