§ Mr. Nigel Spearing (Newham, South)
I wish to raise aspects of the London Ambulance Service. I am grateful to the Minister for being here at this time. We haw this practice of airing grievances before the Adjournment and my grievance is deep. Although I appreciate the Minister's presence, I make no apology for raising this matter because I do not think that she understands — I hope that she will by the time I have finished—the extent of the inconvenience and distress being caused by heir Department and its works to thousands of people in London and to the employees of the London Ambulance Service, as well as the knock-on effects on doctors, outpatient departments and families throughout the metropolis.
In reply to earlier debates, the hon. Lady properly stressed the nature and concern of care and, in particular, the effect upon the individual. On several occasions she has reminded us of happy outcomes and marvellous things that the Health Service is doing. I am afraid that she will have little scope for that in her reply to what I have lo say today because I believe that there has been a major sequence of maladminstration in the Health Service, which has caused a great deal of submerged unhappiness. I look to her to put it right. If she is concerned to achieve happy outcomes such as she has cited, I hope that she and her senior colleagues will do something about the matter that I now raise.
The North East Thames region has featured in a previous Adjournment debate, and my constituency of Newham is in it. We have our own district health authority, which is subject to the regional health authority. However, as the hon. Lady and others may know, the London Ambulance Service is run on an agency basis by the South West Thames regional authority for all the authorities in London. That causes an administrative layer and difficulties that might not appear elsewhere, but I fear that what has happened in London is happening elsewhere, although in London the administrative knock-on effect may be greater because of that structure. I should prefer the London Ambulance Service to be responsible to an all-London elected body but, alas, the Government have not regarded that and the service was removed from the care of the Greater London Council some time ago.
When we think of ambulances, we think of the emergency ambulances rushing through the streets, perhaps with a case aboard, and we drive to the side of the road to let them by. However, two to three times the amount of mileage is done on non-emergency services, carrying people who have to attend outpatient clinics and calling for them at their homes. Most often those people are not on stretchers. Sometimes they are in wheelchairs, but sometimes they are classified as ambulatory. It is to those non-emergency services in London and elswhere that I refer exclusively today.
In 1983 the Government established a Rayner-style departmental survey of the service. Under the guidance of the chairman of the East Birmingham health authority, Mr. James Ackers, the assistant district administrator, Mr. B. R. Payne, reported in March 1984. It was a long report and I do not intend to quote from it at length. The upshot was that Mr. Payne believed that there was some misuse of non-emergency ambulance services by people who 659 might have walked. The letter that I shall read later talks about people getting to the hospital by other means rather than being carried by those expensive services.
In addition, there was some administrative slippage in the service, and Mr. Payne thought that a link between those who paid for it, particularly the district health authority, and those who used it, would lead to greater efficiency, although in his report he said that he thought that the extent of misuse was no more than 4 to 10 per cent. Of course, one man's idea of misuse may be another man's idea of non-misuse—it is a variable term.
Mr. Payne's calculations showed that there could be a saving in expenditure of about £9.4 million. The Secretary of State said in a letter dated 17 March 1984:The report identifies as the major weakness in the control of the non-emergency service the fact that those DHAs which do not have the responsibilty of managing it are able to make demands on it without direct and immediate financial consequences to themselves. The main recommendation is that the ambulance service should provide a given quantity of service to each DHA at an agreed cost and the DHA should develop a means of including an agreed element in unit or clinical budgets for patient transport. It would be open to districts to buy in part of the service from other public agencies or the private sector if this was more cost-effective, providing the quality of the service was maintained.I emphasise those final words. In the middle of his statement, the Secretary of State used a deterministic phrase when he said that the serviceshould provide a given quantity of service to each DHA".In other words, the superior authority will decide how much is to be provided and that will be that unless very stretched financial resources are used for buying in more services. That is administration from above and, I put it to the Minister, a dreadful mistake. The important question is how much will be provided. In London, there is a considerable cut.
On 3 June, I asked the Minister's predecessor:What requests have been made by the South-West Thames regional health authority to district health authorities in respect of the use of the London ambulance service; what is the target of that authority's request for redirection in the number of 'non-emergency' cases to be carried?He replied:In a letter dated 20 March 1986, the South-West Thames regional health authority asked district health authorities to reduce the demand for non-emergency ambulance transport for walking cases by 40 per cent."—[Official Report, 3 June 1986; Vol. 98, c. 540.]That is an extraordinary figure — 40 per cent. of one category of patients were no longer to be carried by the London Ambulance Service. In fairness, I must stress that it was not 40 per cent. of all non-emergency cases but 40 per cent. ambulatory non-emergency cases—people who might be considered able to walk or to get to hospital by other means. But who decides that?
I have been in correspondence with the chairman of the South West Thames regional health authority — Sir Antony Driver—to clarify that draconian cut. I shall quote from his letter because it is fair and instructive to do so. He explained that the patients who were carried and regarded as walking patients were only a proportion of non-emergency cases. On his calculations, the reduction was nearer 12 to 15 per cent. of overall non-emergency cases than the 40 per cent. figure which he had previously given. He said:The further complication in using figures such as those which you quote"—660 —the Minister's figures, not mine—is that the demand level for non-emergency transport is very much a matter of clinical decision, and in the past it is the unfortunate truth that doctors have not been as critical in examining the need for expensive ambulance transport compared with other forms as they might have been, and it is only now, during the period when the service has been unable to fulfil all the demands, that they have been required to be more critical. It is our earnest wish that the Ambulance Service continues to carry all patients for whom ambulance transport is clinically essential.That is Whitehallese, "Yes, Minister" stuff. I wish to do a little exegesis on that bureaucratic letter. The chairman admits that the health authority has not been able to fulfil all the demands. That happened, of course, because of the cut of 40 per cent. in walking cases required by the Minister and, in turn, by the regional health authority.
The chairman said in his letter that doctors had not been so critical in examining the need for expensive ambulance transport as compared with other forms. What does he mean by "other forms"? Does he expect people literally to walk to hospital, to use the bus for outpatient treatment or to ask friends with cars to give them a lift? Those alternatives may be possible for many people. Doctors would not have expected ambulances for those people, but I understand that in a high proportion of non-emergency cases ambulances are requested by doctors.
What about the phrase "clinically essential" used by the chairman? I would have thought that a caring society and a caring NHS would have preferred either "clinically desirable" or "clinically advisable". We all know that even when in the best of health, on an off day we do not feel too good. Elderly people should not have to find their own way to hospital; it is far better that an ambulance be provided. The Minister has referred to the high proportion of elderly people in the nation. A high proportion of non-emergency ambulance cases are elderly or disabled people.
The 40 per cent. cut has been defended by the chairman, so the hapless district authorities or other regional authorities that rely on him to provide ambulance services must follow suit.
In practice, difficulties can be even greater than I have described. Even given a certain amount of increased efficiency in the handling of ambulances—which was fairly pointed out in the Rayner-style report—difficulties will arise. For example, there will be traffic problems, delays, difficulties with grouping people, waiting for people to leave outpatients, and so on. Theoretical mathematical calculations do not always work out.
In the north- east Thames ambulance division in March this year there were up to 200 cancellations a day, amounting to between 600 and 700 cancellations a week. I understand that in Newham general hospital, which is already 70 per cent. oversubscribed for its emergency services, there was about a 20 per cent. cancellation rate. The effect of that is considerable and the difficulties for the doctors and the outpatients can only be imagined. People wait for the ambulance, but do not know whether it will arrive. I understand that up to 12 cancellations were made for one of my constituents, and many hundreds of them had their appointments cancelled. Anyone who has used the appointment system in an outpatients department knows how complex it is to obtain one. Imagine then sitting waiting for an ambulance that does not arrive.
In north-east London during the last few months, and especially in Newham, the rate of cancellations has 661 reached alarming and unacceptable proportions, especially for the elderly. Let us consider the difficulties for their families, who want to know whether they have been able to attend for their appointments and whether they can get home again. In many cases patients have been delayed when trying to get home. I have even heard of cases where, because ambulances were not available, the hospital staff—out of the goodness of their hearts—have obtained minicab services, no doubt at extra cost to the NHS.
The Minister has made it plain that she understands the problem. The cumulative anxiety of those wishing to go to hospital, their relatives who may be at work and the people who try to help out is enormous. The Government have created an administrative knock-on effect on an enormous scale. They talk of a caring Health Service, but it is unquestionable that there is a serious effect on family life, on out-patient departments and on the morale of the people who operate the service. The latter are subjected to questioning and abuse when patients arrive. They are expected to be proficient but are not given the tools or manpower to do the job. It is almost impossible to quantify the social disease that that process engenders. All hon. Members will appreciate that point from experience of their own communities.
On 3 June, I asked the then Parliamentary Under-Secretary of State, the hon. Member for Wycombe (Mr. Whitney), some questions and received almost unbelievable replies. He said that in 1985 the London Ambulance Service ran nearly 3.7 million ambulance miles for emergencies and 7.7 million ambulance miles for non-emergency services. I have been told by people who use a wheelchair that ambulances without a tail-lift often arrive to collect them. The projection for 1986 is that emergency miles should remain much the same at 3.8 million but that non-emergency miles should be reduced to 6 million as a direct result of the Rayner study and the Minister's letter. That is a reduction of 1.7 million miles per year, or more than 20 per cent.
The consequences of the reduction in terms of human impact are mind boggling. Is the Minister suggesting that needs have fallen by anything like that amount or that there is that much misuse of the service? Like all other hon. Members, I as a taxpayer am prepared to ensure that, even if there is 10 per cent. misuse of the service, the other 90 per cent. should get the service that they need and on time. Hospital workers can then provide an efficient service. Goodness knows, they are under enough pressure as it is. The Rayner study is an irregular form of administrative study. By Government fiat, originating with the Prime Minister, after one letter from the Minister and one investigation by one assistant administrator in one health authority, we now have chaos and distress affecting a large number of people in London.
The hon. Lady has told us that she is a caring Minister. This is a short notice debate and I am grateful for her presence, but we look to her to give an undertaking to examine this matter. I do not believe that this caring Health Service and its caring Ministers can prove their point until we get back something like the 1.7 million ambulance miles that have been lost to the people of London.
§ Sir Bernard Braine (Castle Point)
I must apologise to you. Mr. Deputy Speaker, to my hon. Friend the Minister and to the House for not being here when my hon. Friend 662 the Member for Southend, East (Mr. Taylor) was unexpectedly called to make his Adjournment debate speech. I shall be all the briefer because the hon. Member for Newham, South (Mr. Spearing) has since raised an important issue and is entitled to an answer before we rise.
The matter raised by my hon. Friend the Member for Southend, East touches on his constituency, mine and others. It concerns the provision of radiotherapy and cancer treatment services for a very large number of our people. I shall not go over the ground again because I have no doubt that it has been covered most adequately. I merely wish to reinforce the plea that I know will have been made against the regional health authority's proposals for the relocation of the first-class long-established and highly reputable cancer services at Southend.
The regional health authority has had three attempts at moving the goal posts to Chelmsford, Runfold and Harold Wood and has not come up with any real solution to the problem. It has not taken into account the terrible distress caused to cancer patients in our constituencies who have to travel considerable distances for treatment two or three times a week. The regional health authority's proposals have caused not only widespread dismay but great anger throughout south-east Essex. It is unbelievable that its proposals do not save money, but will, in fact, cost more.
I have written to my hon. Friend the Minister in detail about the matter and will do so again, but I simply want to state here and now that the NHS exists in order to deal with sick people as efficiently and humanely as resources permit. Instead, the regional health authority has caused immense distress and anxiety. It has taken over a year to arrive at a proposal that satisfied no one. I do not mean just ordinary lay people such as myself and my constituents and cancer sufferers and their relatives; I mean the Essex medical committee and the consultants caring for patients. I hope that my hon. Friend will lake this expression of deep dissatisfaction seriously and will take a personal interest in the matter with a view to ensuring that when my right hon. Friend the Secretary of State comes to make a decision he is fully informed.
§ The Parliamentary Under-Secretary of State for Health and Social Security (Mrs. Edwina Currie)
I know that my right hon. Friend the Member for Castle Point (Sir B. Braine) must be disappointed at the way that the systems of the House operated today so that he could not be present for what I hope, on reading the Official Report tomorrow, he will agree was a useful and timely debate. I know that he had made representations to Ministers and the regional health authority and has effectively represented his constituents' worries on this matter, and I am sure that he will continue to do so. I hope that he will take note of what was said this morning and I shall be pleased to hear his further comments. I am grateful to him for supporting his constituents in the way that he has today.
The hon. Member for Newham, South (Mr. Spearing), as he said, has asked questions on the London Ambulance Service and he is not alone in that. For example, questions have been put down by the hon. Member for Peckham (Ms. Harman), and on 18 May 1986 my hon. Friend the Member for Ravensbourne (Mr. Hunt) had an 663 [The Parliamentary Under-Secretary of State for Health and Adjournment debate on the subject which the hon. Gentleman can find, should he so wish, at columns 956 to 962 of the Official Report for that day.
The British ambulance service has been the subject of much scrutiny and change recently, partly, as the hon. Gentleman said, as a result of the Rayner scrutiny, which appeared some years ago. Most recently, the pay structures have been changed and the pattern of working of the service has been altered.
The salary structure agreement for ambulancemen came into effect on 1 March 1986 and it radically changed the pay arrangements for ambulancemen. It provided an opportunity for all ambulance services to rid themselves of inefficient working practices. It was intended that the changes would lead to a more efficient and effective ambulance service more sensitively geared in terms of staff deployment to patients' needs.
The agreement was reached in the ambulance Whitley council and was warmly welcomed at the time by all parties. I have recently had the opportunity to meet some of the members of the trade unions concerned at that time and to thank them for the immense amount of effort that went into negotiating that agreement and its subsequent implementation. All the details are not yet worked out. For example, ambulance officers are still the subject of some discussion. However, my Department would wish me to put on record the fact that we appreciate the enormous effort that went into negotiating that agreement by all concerned, not least by the trade unions.
There was no intention that the level of service provided to the general public should be reduced as a consequence of the agreement. The purpose of the salary structure was to replace a pay system which encouraged inefficient working practice. Both management and the trade unions recognised the importance of reducing overtime to the absolute minimum necessary for operational purposes and the need to eradicate other working practices which frustrated the establishment of a modern, cost-effective, efficient ambulance service.
The inclusive salary will replace the former pay system in which the basic rate of pay was substantially enhanced by additional payments for overtime, shift and weekend working. It also subsumed bonus payments previously paid to many services, but not to the London Ambulance Service. Overtime levels in the London Ambulance Service in the previous year, however, equated to 488 full-time equivalent staff, or about 20,000 hours a week.
I hope that the hon. Gentleman will join me in deploring any system which relies so heavily on overtime to pay people a decent wage and which so destroys the opportunity that others may have of joining the service when so much of the service is provided on an overtime basis. He and I share concerns about young people who seek jobs and sometimes cannot find them. I hope that we can be reassured that the ambulance service at least and, indeed, many other parts of the NHS are doing their bit to ensure that we have more names on the payroll while we get the work done as efficiently as possible.
§ Mr. Spearing
The Minister may well be right and, obviously, we want the service properly staffed, with proper wages and a career structure, but that was not the burden of my remarks. Is the Minister suggesting that the talks or difficulties that she mentioned have in any way 664 influenced the 40 per cent. cut in ambulant cases or the administrative instructions? She will agree that, although they are interesting, they are irrelevant.
§ Mrs. Currie
On the contrary, they are directly relevant. I hope that the hon. Gentleman will bear with me as I attempt to put the case as I see it and in such a way that the background can be fully explained.
The basic rate of payment now covers all payments of a standard working week, work round the clock and seven days a week as required. The national agreement also provided local management with the opportunity to review critically working arrangements in a number of areas. For example, the level of accident and emergency cover was to be reviewed to ensure that the level provided matched that indicated by operational need. You will see, Mr. Deputy Speaker, that in one sentence I have answered the hon. Gentleman's point.
Provision was also made for rotas to be reviewed and, where necessary, changed, using the criterion that operational necessity is the basis for staff being on duty, and operational necessity alone. Out-patient and day-centre arrangements were also to be reviewed and altered to provide optimum vehicle and manpower utilisation. The agreement further provided for a commitment for working practices to be kept under continuing review and for changes to be made where indicated. It also provided for the extended training of ambulance men and women and for them to practise extended skills without further payment.
The basic management principle on which the salary structure was based was carefully worked out with specialist experts. The expectation was that salaried status would lead to major changes in the organisation and delivery of ambulance services and to an improved service for those patients who needed it. However, it was realised that the full benefits of the agreement would take time to materialise, and that the pace of change would be variable across the country and depended critically on the ability of management to secure these changes. It is not surprising that there were teething troubles in some areas and it cannot be denied that there were and perhaps still are particular problems in London.
Prior to the introduction of the salary structure in March, the London Ambulance Service management reviewed its working arrangements and reached local agreement with the staff about the changes necessary to provide the level of service that it considered appropriate.
It decided that there was an immediate need to improve the quality of the emergency ambulance service in London. Changes were therefore introduced on 1 March simultaneously with the introduction of the salaried structure. More resources were diverted into the emergency side of the ambulance service, and these have helped to improve response and activation times, producing a better emergency service for patients. Clearly, that was a worthwhile development, and I hope that the hon. Gentleman can welcome it.
September is the latest date for which I have been able to obtain figures, but I understand that then the nationally recommended response times were met in 90 per cent. of emergency cases in London, as against about 85 per cent. previously. But that is still below the minimum standard of 95 per cent. that is set down nationally.
Consequently, we expect to see further improvement. The improvement in the emergency service had an 665 immediate impact, however, on the volume of non-emergency ambulance services in London. That occurred because the manpower available to carry out non-emergency duties was temporarily reduced and new staff needed to be recruited and trained. That led to major problems during March and April, and a considerable number of complaints resulted.
Since then, however, the situation has improved considerably. The full benefit of additional staff will not yet have been felt, because of holiday absentees, but during October we hope that the full impact should have become apparent and we are assured that within the next few weeks a large number of staff who are full-time, part-time and training will come on stream. The London Ambulance Service is particularly recruiting part-time staff to cover day hospital work, which will in time release full-time staff to deal with out-patient work. Thus positive measures have been taken to improve the undeniably difficult situation that existed earlier in the year.
I hope that the hon. Gentleman will agree that the most important thing is to ensure that the ambulance service is being used effectively. It is not a taxi service, or a free bus service. It is quite inappropriate that skilled personnel and expensive equipment should be used in anything but the way in which they were intended.
The hon. Gentleman spoke about ambulant non-emergencies. Surely he agrees that a substantial proportion of ambulant non-emergencies should be able to reach the care that they require without the assistance of the ambulance service, whether they are going to the hospital, day centre, clinic or a GP's surgery. The hon. Gentleman should address himself to that principle.
§ Mrs. Currie
I am sure that the hon. Gentleman can find it in himself to accept the general principle that equipment should be used for the purpose for which it is provided.
He mentioned the mileage being covered. I refer him to a written answer given on 24 July 1986 and to volume No. 102 of the Official Report, columns 445 to 446. The hon. Member for Peckham asked what mileage was covered by ambulances run by the London Ambulance Service in the South-East Thames region in 1985. She also asked for the estimate for 1986. She was told that in 1985 the emergency service mileage amounted to 808,687 miles. The estimated mileage in 1986 was put at 838,000 miles. That is an increase of about 30,000 miles a year. The non-emergency mileage in 1985 was estimated to be 2,029,105. We estimate that the non-emergency service should provide around 1.6 million miles. In other words, there is quite a substantial drop of about 400,000 miles a year. Those figures are for the south-east division of the London Ambulance Service, which follows the south-east Thames boundary but includes Croydon.
Such figures confirm what the hon. Gentleman was saying. But in his reply to the debate on 15 May 1986, which was raised by my hon. Friend the Member for Ravensbourne, my predecessor said:The London Ambulance Service management has reviewed its working arrangements and reached local agreement with the staff about the changes necessary to provide the level of service it considers appropriate. It decided that there was a need to divert more resources to the 666 emergency side of the ambulance service … I believe that it will be welcomed by all hon. Members."—[Official Report, 15 May 1986; Vol. 97, c. 960.]That is what was intended, and that is what has happened.
In my response on 24 September 1986 to a letter from the hon. Member for Peckham dated 18 July I was able to update the training figures. I told the hon. Lady:As you will know, the South West Thames Regional Health Authority (which manages the LAS on behalf of the four Thames regions) acknowledged that problems had arisen on the non-emergency service and began taking positive measures immediately to overcome these difficulties. Their urgent measure to recruit and train additional staff has succeeded in providing over 140 additional ambulance personnel since March for non-emergency work. These people are already operational, and 80 more are now in training.I am advised that we now have 150 additional full-time staff on non-emergency work with 21 part-timers and about 60 personnel in training.
In my letter to the hon. Member for Peckham I continued:The Region has also opened up the recruitment possibilities by seeking up to 300 extra part-time staff to deal with day hospital demand so that full-time staff can be released to carry out important out-patient work. Coupled with this, the Region's actions have allowed more staff to be available for the life-or-death emergency work to ensure that standards are improved in this vital area of the service. I feel that the Regional Health Authority deserves congratulations for the effective and speedy improvements they have made to staffing problems in just a few months.A report in The Guardian of 27 October confirms some of the events. It says that the London Ambulance Service is carrying 30 per cent. fewer non-emergency patients today than it was two years ago. It says that only 27,500 patient journeys per week were being made this year compared with 39,500 in 1984. About 10,500 fewer walking patients were being transported—a reduction of 44 per cent. I am more than happy at that development. We are keen to have a better emergency service. We are determined to ensure that the equipment and resources are not used inappropriately.
The hon. Member for Newham, South said that he would like the LAS to be run by an all-London elected body. I assume that he would have liked the GLC to run the service. Once again Socialist Members are crying over spilt milk, because the GLC has been abolished. However, in its 20 years no attempt was made by any Government to reorganise in that way. The chance was there, but it was not taken. The GLC is no longer there and the ambulance service will not be run as the hon. Gentleman prefers. The hon. Gentleman is at a dead end. I am satisfied that the ambulance service is being run and managed in the interests of patients.
The hon. Gentleman is right to express worries, but it is also right for the Government to ensure that regional health authorities and those managing the ambulance service can guarantee the efficient use of skills and equipment. The ambulance service is part of health care. It is not a taxi or a bus service. It is no more acceptable for an ambulance to be used inappropriately than it is for an operating theatre to be used inappropriately. I am sure that the regional health authority and the London Ambulance Service are taking careful note of the points that have been made, and I am grateful to the hon. Gentleman for raising them this afternoon.
Question put and agreed to.
Adjourned accordingly at nineteen minutes past Two o'clock.