PARLIAMENTARY DEBATE
Ambulance Pressures - 18 July 2022 (Commons/Commons Chamber)

Following the announcement by the Met Office on Friday of a red warning for extreme heat, I would like to update the House on the impact of extreme weather on health and care, the current covid infection situation and our plans for covid and flu vaccines this autumn.

This is the first time in its history that the Met Office has issued a red warning for extreme heat. The warning covers today and tomorrow. In addition, the UK Health Security Agency has issued its highest heat alert. Its level 4 alert, issued to health and care bodies, means that the heat poses a danger to all of us, not just high-risk groups. Although for many the risk from this heat can be mitigated by simple, common-sense steps, the extreme temperature poses a particular risk in respect of cardiovascular conditions, including heart attacks and strokes. Level 4 does not change the contingency plans in place across the health system, only their likelihood.

We have taken a number of steps in response. Cobra has convened several times, including over the weekend and earlier today, to co-ordinate every part of the Government’s response to this emergency, and I have held a series of meetings with the chief executives of ambulance trusts to discuss the specific measures that they are taking. Steps include increasing the numbers of call handlers; extra capacity for ambulances; and extra support for fleets, including the buddy system, so that calls can be diverted to another trust if there are delays in the area people are calling from. We have held numerous meetings with NHS leaders, including the chief executive of the NHS and her senior team, to continue to implement their long-standing heatwave plans. We had a further meeting again this morning. Meanwhile, ministerial colleagues have continued to liaise with our local resilience forums to co-ordinate across both health and social care.

Even before this heatwave, ambulance services in England have been under significant pressure from increased demand, just as they have across the United Kingdom. The additional pressure on our healthcare system from covid-19, especially on accident and emergency services, has increased the workload of ambulance trusts; increased the average length of hospital stays; and contributed to a record number of calls. Taken together, that has caused significant pressures, which are now being compounded by this extreme heat.

We are taking action in a range of areas. In May, NHS England published a tender for auxiliary ambulances to provide national surge capacity to support ambulance responses during the period of increased pressure. Alongside measures in ambulance trusts to assist with call handling and capacity, NHS hospital trusts are taking steps to address handover delays, in the interests of patient safety. On Friday, the NHS medical director, Steve Powis, and the chief nursing officer, Ruth May, wrote to the chief executives of NHS trusts, ambulance trusts and integrated care boards setting out some of the urgent interventions we need to make; most significantly the focus was on improved ambulance handovers and increased hospital bed capacity.

On ambulance handovers, we are asking health leaders to look again at the balance of risks across the system. We know that leaving vulnerable people in the community would have serious implications for patient safety. Equally, we know that keeping people in ambulances for too long carries other risks, especially from heat. NHS leaders are therefore asking hospital trusts to create additional space for new patients in their units. That may involve the creation of observation areas or exploring ways to add additional beds elsewhere in hospitals, including by adjusting staffing ratios where necessary, as we did during covid, and working to identify areas to mitigate additional workload, such as through greater support on wards with pharmacy and administration.

The NHS is executing its urgent and emergency care recovery 10-point action plan, which includes action across urgent, primary and community care to better manage emergency care demand and capacity. The NHS medical director and chief nursing officer both recognise that this will place an additional burden on some staff, so they are asking trusts to increase efforts on staff wellbeing and support. Alongside the measures being taken by the ambulance services and NHS trusts, the UK Health Security Agency is leading on public health comms to reduce the burden on NHS staff by making sure that we do not create unnecessary demand. We can do that by following the common-sense public health guidance and by looking out for others, in particular the elderly and the vulnerable.

With services under so much pressure, we must make sure that 999 calls are reserved for life-threatening emergencies. We must also consider what advice we can get through other services such as NHS 111, NHS online resources and local pharmacists. In addition to the immediate steps to mitigate the pressures on 999 calls, ambulance services and adult social care, we will keep building on our operational response, with particular attention to discharge and expanding on our pockets of best practice.

That is particularly pertinent, given the current levels of covid, which continue to rise. The latest data from the Office for National Statistics shows that the percentage of people testing positive for covid continued to increase across the UK. In England, an estimated one in 19 people tested positive in the week to 6 July, compared with an estimated one in 25 during the previous week, with more than 13,000 patients admitted to hospitals with covid-19.

Given those pressures and the expected pressures this autumn and winter from respiratory viruses, we are taking important steps to further align our offers on covid and flu. On Friday, I accepted the Joint Committee on Vaccination and Immunisation’s recommendations for a covid-19 autumn booster programme, focusing on vulnerable cohorts, including everyone aged over 50. At the same time, I took the decision that we should keep offering flu jabs to more cohorts than we did before the pandemic. Taken together, this will reduce the number of people getting seriously ill this autumn and winter, easing pressure on the NHS at a critical time. Vaccines have always been, and continue to be, one of the best protections we have, both for ourselves and for the NHS.

From this heatwave to the foreseeable pressures in autumn and winter, I will continue to work closely with colleagues across health and social care, as well as with Members across the House, to ensure that we can address the challenges ahead. I commend this statement to the House.

Let me start with the area on which the hon. Lady was correct, which is that I recognise the increased pressure on ambulances and hospitals. That is why we put in place the long-established contingency plans. Since the heatwave in Paris in 2003, it is the case that each year in May, we put in place our heatwave plans. That is what has been activated. Those plans were refreshed as recently as two months ago and sit alongside the work that has been done on urgent and emergency care, including the 10-point action plan that was set out last September.

The hon. Lady is right: the House as a whole will recognise the significant pressure on the system, which is why we are taking the steps from our contingency plans. It is also why we have put in specific funding, such as: the additional £150 million of support targeted at the ambulance service; an additional £50 million for 111 calls to build capacity; and as she said, an additional £30 million for auxiliary ambulances, which is what the Minister of State, my hon. Friend the Member for Lewes (Maria Caulfield), was referring to in the House last week.

The Met Office and the UK Health Security Agency went to level 4 on Friday. As you will know, Madam Deputy Speaker, I updated the House on the first available sitting day after that. The irony will not be lost on the House that this issue is seen as so important that the shadow Secretary of State for Health and Social Care has failed to turn up to this statement in the middle of a heatwave. [Interruption.] Well, he is not here, which speaks for itself.

The hon. Lady also suggested that these challenges, which are being faced across Europe as a whole, were in some way due to the overall investment in the NHS. I remind the House that, to take the resource departmental expenditure limit alone, RDEL in 2010 was just under £99 billion and last year it was £150 billion. That is a good indication of the significant funding. We could also come on to capital investment, not least with the 40 hospitals programme, part of a £22 billion package to 2030, which underscores this Government’s commitment to investing in our NHS—an investment that, most recently, the Labour party voted against when we brought it to the House.

The hon. Lady asks about an apology for operational levels of performance. I do not know whether she is asking for that apology from the Welsh Government or just from the English Government. She may want to clarify that, given the performance of the Welsh ambulance service under the Welsh Government.

On the hon. Lady’s point about auxiliary, the Minister of State, Department for Health and Social Care, my hon. Friend the Member for Lewes, said in her statement that we had seen improvements in May. I referred to that as context, but on auxiliary in particular I can clarify for the House that a contract is being procured for auxiliary ambulance services and is expected to be concluded shortly.

Finally, the hon. Lady asked what meetings I have held over the less than two weeks that I have been in post. I am happy to share with the House that I have been on visits to four different hospitals, in Whipps Cross, Hillingdon, King’s Lynn and Bedford; I have been out on two different ambulance shifts, been to three different ambulance centres, been out to see GPs to look at boosting access to their services and been to look at life sciences. I have been engaging, and that sits alongside, for example, the meeting with chief execs of ambulance trusts on Saturday, Cobra on Saturday and other such meetings that I have had in the course of my duties.

Finally, the hon. Lady asked about the Prime Minister’s engagement. Just as the Chancellor of the Duchy of Lancaster set out that he was engaging with the Prime Minister in his role chairing Cobra as Minister for the Cabinet Office, I am happy to confirm to the House that I also engaged with the Prime Minister over the weekend, updating him on the health plans we have put in place. He has been closely engaged on the contingency we have put in place.

I call the Chair of the Health and Social Care Committee, Jeremy Hunt.

I congratulate my right hon. Friend on taking up his post as Health Secretary. Since no one ever thanks you for doing that job, I thank him for doing this tough job. I am delighted that someone with ministerial experience in the Department of Health, who therefore knows what he is talking about from the outset, is doing the job. I welcome his saying in his statement that the ambulance service is under pressure not just because of the heatwave. Does he agree that one of the main reasons for that pressure is that hospitals find it difficult to discharge patients who are fit to discharge into the social care system, and that it is financial madness to look after someone in a hospital at £300 a day when the social care system can often do it at £50 a day? Will he, in his new role, finish the job and put in place a 10-year plan for the social care system and the funding for local authorities needed to go with it?

I am grateful to my right hon. Friend for that warm welcome. I was Minister of State when he was Secretary of State, and hugely valued the expertise, diligence and insight that he brought in that role, which provide useful context as I take on my new duties. He is absolutely right; indeed, he will recall, in 2018, looking in detail at delayed discharge, and work on that key issue continues. For example, on 1 July the NHS launched a 100-day sprint looking at all the known interventions. One issue that he and I have discussed in the past is how to socialise best practice and industrialise innovation at scale, and we are looking specifically at that. There is also a call for expressions of interest in pioneer science to better use tech and innovation on delayed discharge, and of course there is £2.6 billion of investment in the better care fund to support that integration work through the integrated care boards.

Although I welcome the additional resource in response to the heatwave, it is simply not enough. Does the Secretary of State agree that until the Government address the systematic problems in social care to ensure that it is properly funded and people can be discharged quickly into the community, and we no longer see the revolving door service that is proving so damaging in the sector, we will not truly be able to reduce the pressures on the ambulance service?

The hon. Lady brings great practical insight on these issues from her profession as a nurse. The point she raises, as did my right hon. Friend the Member for South West Surrey (Jeremy Hunt), is absolutely right—delayed discharge has long been a key issue. That is why we have made the tough decisions we have on national insurance and why we brought forward the changes on integrated care boards. It is an area of common ground across the House that we need to work better to address delayed discharge, which blocks the pipe and, in turn, delays ambulance handovers and causes problems at an earlier stage. It is a key issue. I have set out a number of practical measures that we are taking, and further work is ongoing.

On Friday afternoon, I spent a shift with the A&E staff at the fantastic Worthing Hospital, which is clearly being impacted, in particular, by older people affected by the heat. The staff said to me—the Chairman of the Health Committee mentioned this—that more than 15% of the beds are being occupied by people medically fit to be discharged. They also said that a huge amount of their time is being taken up by people with mental health problems, including those being brought in by the police, most inappropriately. What more can be done to make sure that people with mental illness are being looked after away from A&E departments, as is far more appropriate, and to speed up the process of freeing up those beds?

My hon. Friend is absolutely right on mental health and where a patient is violent, as I saw for myself on my visit to Bedford, for example, that can be unsettling for A&E. I am happy to have further conversations with him on what measures can be taken. The fact is there is no single intervention in this space; it is a question of looking at the integrated approach. That is what the call for evidence is about. Also key is understanding the data and seeing where it can better target action on areas such as mental health that can have a disproportionate impact.

It is absolutely right that we limit the amount of time that patients must spend in the back of ambulances, and I welcome that measure, but it is putting intolerable pressure on hospitals. This morning, health leaders told me that they simply do not have the space or the staff, and the one thing they need in the next few hours is more staff. Can the Secretary of State commit himself to ensure that in the next few hours there are no financial or other barriers to the NHS being able to access more NHS bank staff, paramedics and ambulance drivers from the fire service, and, if necessary, from the military?

The principle of subsidiarity is that, as part of the extreme heat plans, local trusts make decisions locally on targeting resource, whether that has an impact on outpatients or other services, to meet the increased pressure. The hon. Lady is absolutely right that there is significant increased pressure, as we see in the call volumes coming in to 999 and 111. Part of the contingency plans that are in place is to surge resource, but it is also partly about being clear where risk best sits. At the heart of the letter from NHS medical director Stephen Powis on Friday was the importance of not pushing risk out into the community where it is an unmet need, or into the ambulance, where it is best that patients are, but having that risk more on the ward, where a patient is known and can receive care. Local contingency plans are in place to allocate resource to meet that.

I pay tribute to all my Mid Sussex constituents on the frontline of all our emergency services in this extreme heat. They are absolutely continuing their heroic efforts, whether on the NHS backlog, managing discharges, as we have heard, or managing the impact of covid. Following recent media reports, will the Secretary of State note the constraints in certain ambulances, which my constituents have also raised, with cabs being too small and seatbelt use impacted for those over 6 feet tall? The impact of those new ambulances is on the agenda at a meeting for West Sussex MPs with SECAmb—South East Coast Ambulance Service NHS Trust—this Friday.

First, I am happy to join my hon. Friend in paying tribute to the work of the local staff in her ambulance trust. She raises an important point about the fleet, and I was very interested in this issue four years ago when I was ambulance trust Minister and discovered that there were, I think, 32 different types of ambulance. When I was out with crews over the past fortnight, one of the issues we discussed was the merits of tailgates so that people are not suffering work absence and musculoskeletal injuries because they are trying to push heavy loads on to an ambulance. I am interested in exploring with her and colleagues how we get the right standardisation and the right fleet in place. Indeed, we have been targeting additional money to support that work.

Since March, West Midlands ambulance service has been on the highest level of alert, and I understand that it was joined by the other ambulance services across England last week. In May, Mark Docherty, the director of nursing for West Midlands ambulance service, predicted that the service would collapse by 17 August—that is a month away from now—if hours lost by crews delayed outside hospitals kept increasing, which of course they have. Can the Secretary of State give some specific answer on what he is doing to address the issues in the west midlands, and also in our care homes, which are a root problem of trying to get people out of hospitals?

The hon. Gentleman is right that the west midlands in particular has been under significant pressure, and 111 ambulance service response times are significantly challenged, which is driven by wider system pressure and delayed handing over of patients. The measures taken through the national support that is going in include handover delay improvements, on which works is taking place across all integrated care boards. NHS England has allocated an additional £150 million to support the system, and an extra £20 million of capital is going into fleet. Given that I am new in post, I am happy to meet the hon. Gentleman to discuss any specific issues about the West Midlands ambulance service’s performance.

May I congratulate my right hon. Friend on his new role and say how important, given this particular crisis, his previous experience as Minister of State for Health is? He took over that role from me, and he had ministerial responsibility for ambulances.

On Friday, I attended an ambulance summit with other Shropshire and Telford MPs, West Midlands ambulance service and NHS leaders in Shropshire, where we were told that one of the critical issues in ambulance response is the handover wait times at hospitals. Royal Shrewsbury Hospital was averaging two and a half hours for handover in the first two weeks of July, and the Princess Royal Hospital in Telford was at three hours.

The problem is not so much conveyance by ambulance because it is hard to reach patients, but ambulatory walk-ins at our hospitals increasing the volumes of patients being seen in A&E. The problem with that increase in patient volume is patient flow and discharge at the far end. May I suggest that the quick win would be to increase resources for social care, particularly for domiciliary care workers who at present, particularly in rural areas, have to pay for their own transport to get from one patient to another? If we could improve those conditions, it would boost the ability to discharge patients.

My right hon. Friend, partly through the direct experience he brings to these issues, highlights the integrated nature of the challenge we face and in particular the importance of getting the right domiciliary care and care home support in place. Part of that challenge in the coming weeks, ahead of any autumn and winter pressure, will be to understand what the capacity is and what the constraints on it are, so that through the integrated care boards we can better focus on unlocking that capacity to relieve the pressure on ambulance handovers, as he sets out.

Older and more vulnerable patients can become medically compromised very quickly in extreme heat. In Yorkshire, category 1 calls can be waiting for 9.5 minutes over the expected time, category 2 calls can be waiting for 18 minutes over, and those with other medical conditions can be waiting 2 hours 41 minutes over. People clearly need support and assessment far earlier. What is the Secretary of State doing to deploy first responders in such areas so that people can get a medical assessment and early intervention far quicker?

I broadly agree with the hon. Lady on providing targeted support, particularly to those in domiciliary care; we are working with those in primary care on that. In coming days, that will happen specifically through local resilience forums, but in the medium term it will be more through the integrated care boards. That is part of a wider package of support measures that need to be put in place. It will include working with primary care, looking at mental health support, and looking at what can be done to raise productivity through better use of innovation and technology. We will look at all the interventions available across the board to assist us in dealing with the pressures that she highlights.

I spent this weekend on duty, in my role with the Yorkshire ambulance service. I remind my right hon. Friend of the important work and extra resilience that community first responders will provide in the next few days, as they are stepped up and attend the most serious 999 calls. The reality is that even before this situation, when attending very serious cases, we were often waiting much longer than we did in the past for back-up from the crew. Will he look at a model that I have pushed before: the advanced paramedic model, which gives paramedics more clinical confidence to discharge patients to their home, and so reduces demand on hospitals?

I am happy to look at that, and I thank my hon. Friend for his service locally. I am keen to follow up on his point, because it is absolutely right. From the feedback from ambulance trusts so far, it seems that category 2 average response times were broadly stable at the weekend, but how we triage, how we categorise calls, and what additional support can be given by considering the skills mix are all factors in improving performance.

I also attended the meeting on Friday morning about Shropshire’s health crisis, and I echo the comments of the right hon. Member for Ludlow (Philip Dunne) on that. Quite apart from this week’s heatwave, there is increased demand on Shropshire’s ambulance service, and the local team are clearly working hard to find solutions, but I did not feel reassured that they had any quick fixes for this crisis. One of their big problems is with recruiting social care workers; the team say that they have never seen a market like it. What is the Secretary of State doing to address the critical workforce problem in social care, not only in rural areas but across the country?

Through initiatives such as the better care fund and the £2.6 billion of investment, we are looking at how to allocate funds in an integrated way. That requires better integration of data between the care sector and the NHS, and that is an area that I am keen to explore.

I recently had the good fortune to spend a few hours with an ambulance driver from Ashfield who drives for the East Midlands ambulance service. He told me that he is so frustrated, because a lot of the time, the ambulance gets to the caller, and the person simply does not need an ambulance. He raised this with his bosses, but they are scared to admit that. Is it not about time that somebody from the Department of Health and Social Care had an honest conversation with the people who actually do the graft—the drivers and the ambulance staff?

I know from conversations in recent days that there has been significant work around dispatch, the assessment of calls and the role of clinicians, particularly in 111. There is further work with frequent callers. I went out with the London ambulance service, and one of our visits was to someone who had had 140 ambulances visit him over the past year and a half. There are initiatives, and work going on, on how we assess calls and get dispatch right, but I am very happy to take forward the comments that my hon. Friend makes.

I, too, congratulate the right hon. Gentleman on his new post.

The Chair of the Health and Social Care Committee raised the question of what happens when people are ready to go into the community, but there is nowhere there for them to go. There is an even worse example: people who have major brain injuries, for instance as a result of a road traffic accident. The ambulance staff will get them to the major trauma centre, which will save their life, but if they are to get back their life with any degree of independence, they need a prolonged period of neuro-rehabilitation. Some of that will happen in hospital, but across large swathes of the country, there is nothing—absolutely no provision—outside hospital. With any other condition, we would not expect treatment, once started, not to be finished. How can we make sure that neuro-rehabilitation services, which give people back their life, are available across the whole country, and that there is no postcode lottery?

I know the hon. Gentleman is co-chairing, with the Minister for Care and Mental Health, a strategy board looking at these issues, and I would be very keen to explore that with him in due course. There is an opportunity—not just from a health perspective, but from a levelling up perspective—to look at the pockets where there are gaps in the way he sets out, and to see how we can get better coverage geographically as well as address the very real health needs he identifies.

My constituents attribute the deteriorating response times in Rugby to the decision of the West Midlands ambulance service to close our community ambulance station at the Hospital of St Cross—a decision taken without reference to doctors, councillors, residents or the local MP. Does the Secretary of State agree that decisions of that nature should be made only after consultation and with the support of local stakeholders?

I do not know the specific circumstances of the case my hon. Friend highlights, but in general good consultation and engagement with stakeholders will of course lead to better and more informed decision making. Where decisions have been taken and the outcomes proceed in a sub-optimal way, I know from my knowledge of my hon. Friend that he will make such a case in the strongest terms.

It is worth remembering that the 2010 to 2015 Conservative Government took £6 billion out of social care, so it is no wonder that we are facing a logjam. Since 2015, not once have the Government hit their four-hour target at A&E, and it is down to less than 72% on average right now. This logjam is created by the Conservative Government’s mismanagement of our national health service, so what is the Secretary of State going to do to get back to the four-hour target for A&E?

This Government are investing in our NHS. That is why the resource departmental expenditure limit, which in 2010 was £99 billion, went up last year to £150 billion. It is why we are investing more than £10 billion in capital this year alone. It is why the NHS will get an uplift of about £38 billion over the five years from 2019-20 to 2024-25, and it is why this Government have invested in our 40 hospitals programme as part of a £22 billion commitment.

We have seen some serious issues with the West Midlands ambulance service and congestion at the Royal Stoke University Hospital, and it is only a few years ago that we saw people dying in the corridors at that hospital. Will my right hon. Friend look at what we can do to address these issues, and ensure that we do not just move people from queuing outside the hospital back on to high-risk corridors?

That specific point about where risk best sits within the system was addressed in the letter from the NHS medical director on Friday. Of course, the best way of addressing that risk is to address the issue of delayed discharge. We are getting people out of hospital through initiatives such as the better care fund, the £2.6 billion of investment and the use of integrated care boards. Their use will enable us to take a more integrated approach to unblocking those who are in hospital unnecessarily, which is not only very expensive but fundamentally bad for their care. It is important that we address delayed discharge as a key priority.

I thank the Secretary of State very much for his responses to the questions that have been asked. To give an example that I hope will be helpful to him—this is a devolved matter—when one of my constituents fell and badly hurt her leg last week on rocks offshore, she was able to send a photograph of her injury, and as a result an ambulance was dispatched urgently and she was rescued. My concern is about those who are not high-tech enough to send photographs of injuries to prove that they are ambulance-worthy. Can I ask the Secretary of State how it would be possible to triage calls in a way that does not put pressure on people, but addresses the potential misuse of emergency ambulance requests?

I am happy to look at any specific issues that flow from the hon. Gentleman’s constituency case. The more we can use tech and innovation better to address those issues at pace, the more that will ultimately lead to better patient outcomes.