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Let us just recall what happens. After a serious accident, an ambulance is called; 75 per cent of accidents are attended within eight minutes. That is not a problem; the ambulances get there. It is pretty good. We have heard of the wonderful services given by the ambulance crews and the paramedics. However, the victims survival depends crucially on their airway being kept open and their brain being supplied with oxygen. That is a basic need that we human beings have; we need oxygen to our brains if we are going to stay alive.
In the past paramedics used to intubate, which means putting a tube down the windpipe of the patient. They could do that only if the patient was unconscious.
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It is worth reflecting on the fact that the mortality rate for severe trauma in this country is 40 per cent higher than in the United States of America. Recently, there was a national confidential inquiry into patient outcome and death, called Trauma: Who Cares?. Incidentally, why is that a confidential inquiry; surely it should be an inquiry? Will someone please educate the Department of Health as to the difference? The inquiry said that many trauma victims, including children, as well as stroke cases and those in diabetic comaspeople with all sorts of conditions need oxygen given to the brain during the transfer to hospitalare dying in this country through a lack of appropriate care. The Department for Transport accident report in 2006 said that there were 3,172 deaths and 28,673 serious injuries across the UK. With proper care at the scene of the accident, studies have shown, over 2,000 lives could have been saved; two out of each three people who died could be alive today if proper care had been available.
In the USA, Australia and many countries in Europe, such as Germany, there is 24-hour, seven-day-a-week pre-hospital care provision. In London, an NHS-funded critical care doctor and paramedic team are on call during the day. That is rather typical of the NHS, I have always thought. Apparently people do not have accidents or get seriously ill at night. If you are going to be ill or crash you car, you should do it in the daytime, for heavens sake. In London, there is a pretty good daytime service, anyway: as we know, there is the air ambulance and good road transit when the roads are free. At night, however, the service is covered by volunteers and the ambulance crews. This should be available countrywide, 24 hours a day, seven days a week. In fact, severe trauma is the only area of the NHS where a patient dies through the lack of a doctor.
The British Association for Immediate CareBASICSconsists of volunteer doctors working in their spare time to give care to the desperately injured; they must be tired, and they are not paid. This is a patchy service across the country and yet another example of the postcode lottery. I pay tribute to Dr Phil Hyde, Dr David Sutton, Dr Charles Deakin and many others who work in Hampshire. They not only provide this service voluntarily but have campaigned hard and long to bring it to our attention and to that of Members in the other place. My honourable friend Mark Oaten introduced a debate in Westminster Hall last June, which I hope the Minister has seen; it was a very good debate.
We have recently heard of the appointment of a trauma tsar. New Labour loves its tsars; I never understand why it loves them so much, but perhaps that says something about its mentality. We are told that strategic health authorities will be required to have trauma centres, but there is still no planned national service; it is dependent on strategic health authorities. The response is the usual message that primary care trusts and the SHAs are responsible for assessing need in their area. I am sorry, but I do not understand them assessing need in their areas for trauma patients and serious accidents. There must be a pretty uniform rate of accidents throughout the country. This service is needed everywhere and should not be left to the whims of individual area managers.
We know that people will die if they do not receive proper care and oxygen to their brains before they reach hospital. We cannot say that often enough. Again, it is not just trauma patients, but cardiac patients, stroke patients, people in diabetic comas and many, many children. It is a scandal that our health service does not recognise this and ensure that this service is provided. If anything is to be decided locally, maybe it could be whether the service is provided by air ambulance or a fast road vehicle, as that will depend on local conditions, but not the trauma itself.
I repeat: trauma centres, yes, but the patients have to get to them alive for them to be any good. That takes time and trained doctors who can attend the scene of the accident in the first place and ensure that the patient arrives alive. The operating framework for the NHS in England for 2008-09 tells PCTs what they must do, but I did not see anything about critical care at the scene of an accident or the requirement to ensure that local emergency care services will provide such a service.
I repeat: a team of one doctor and one paramedic. Those doctors cannot be the doctors who work in the trauma centres or those who work in accident and emergency, who must stay where they are. I acknowledge that extra staff are needed, but we are talking about one paramedic and one doctor, qualified to give anaesthetics and perform intubation at the accident site, on call 24 hours a day. I hope that the Minister will relieve my distress and save lives by telling me that, among the paper storm that comes from the Department of Health, there will soon be one setting up this service.
Earl Howe: My Lords, the noble Viscount, Lord Falkland, has done us a great service by tabling this debate. I thank him for that and for his powerful and persuasive speech. Trauma care is a topic that has received precious little attention in this House during recent years, which I regret because trauma is the fourth leading cause of death in people below the age of 40. In terms of serious injury and long-term disability, it represents an enormous burden on society and the NHS, so it deserves a lot more parliamentary air time. In a given week there are reckoned to be 240 severely injured patients who are taken to hospital across the UK. Collectively, that is a lot of patients. The natural and obvious question that arises is how well or badly we are doing in looking after those people.
Sir George Alberti, the emergency access director, has been studying that very issue. I know that one aspect that he has been examining is the lessons that we can learn from abroad. Comparisons with other countries are never totally straightforward, but it seems that we in the UK are not doing as well as we should or could be. America, for one, is far ahead of us in the percentage of trauma patients delivered alive to hospital. In Germany, there is a nationwide network of air and road ambulances that can, and do, get a skilled doctor to the scene of the vast majority of emergencies within a quarter of an hour, with impressive results. Here, as we have heard, the presence of a doctor at the scene of an incident is a hit-and-miss affair, depending on where you happen to be. That really cannot be a satisfactory situation.
What difference does a doctor make? The noble Viscount and the noble Baroness, Lady Tonge, summarised it very well. The answer is that it depends on the nature of the trauma but, in general, if you have a patient whose airway is blocked and who needs intubating, only a doctor can see to that. Only a doctor can administer the drugs and pain relief that the person is likely to need. If someone has been knifed, only a doctor is capable of opening up the chest at the scene of the incident.
Saying that is not to belittle or detract from the skills of paramedics, who are highly professional and dedicated people, but paramedics are trained only to a certain level. They are not doctors. The 2007 report Trauma: Who Cares?, which has already been mentioned this evening, pointed to a high incidence of patients arriving at hospital with a partially or completely obstructed airway and an unacceptably high incidence of failed intubation. It is interesting that 41 per cent of patients treated by a helicopter-based system were intubated at the scene of the incident. That is nearly six times the percentage of patients intubated by road ambulance crews.
Of course, response times and intubation rates are only proxy measures for what really counts in trauma care, which are long-term outcomes. Here we are in the age of quality indicators and quality accounts, but the amount of public discussion about quality in trauma care has been minimal. I am aware that PCTs and ambulance trusts have been devoting attention to this area and we must hope that the result of this will be a sharper focus on best practice and greater uniformity of care across the country. Published studies have provided clear evidence that an ambulance crew consisting of a doctor as well as a paramedic delivers significantly higher survival rates and lower morbidity. The College of Emergency Medicine has added its weight to this analysis.
The noble Lord, Lord Darzi, has previously indicated his view that we need to move towards developing dedicated regional trauma centres where specialised services can be concentrated. I agree with that, but it is of course only part of the answer, because the logical consequence of having fewer specialist centres is longer distances for very seriously injured patients to travel. That is why there is now so much interest in developing a network of air ambulances. At the moment, air ambulances are run by some 18 air ambulance charities.
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Certainly, the local NHS and the charities should sit down and work out how to move the service forward and how in particular more doctors can be put into helicopters. However, the question that this raises is what benchmarks the NHS and the charities are able to use to agree on an appropriately high level of service. What standards for trauma care should we expect them to aspire to and what in human resource terms does it take to deliver those standards in a given set of circumstances? Those questions can surely be resolved only at national level. I should like the Minister to say whether she agrees with me about that.
We need to grasp the point about standards, which of course applies equally to land ambulance services. The Trauma: Who Cares? report came to the sobering conclusion that nearly 60 per cent of trauma patients received a standard of care that was less than good practice. It said:
The organisation of prehospital care, the trauma team response, seniority of staff involvement and immediate in-hospital care was found to be deficient in many cases. Lack of appreciation of severity of illness, of urgency of clinical scenario and incorrect clinical decision making were apparent ... the provision of suitably experienced staff during evenings and nights was much lower than at other times ... this is a major concern.
That is a pretty serious list of failings and, while some of it can no doubt be addressed by concentrating trauma care into fewer centres, some of it points to the need for national clinical standards and clear guidance on best practice.
I am aware of the framework document published last year that set out a number of recommended management and service standards for air ambulances, but this is not quite the same thing as trying to define the standards that should apply to ambulance care overall. We need to recognise, as that document points out, that pre-hospital emergency care is now a speciality in its own right. There is no doubt whatever that expert critical care at the roadside, if it arrives early enough, has a significant effect on patient outcomes in cases of serious injury. Some ambulance trusts now provide fast response unit cars staffed by individual paramedics. These are helpful in a lot of cases such as heart attacks, but they cannot be a substitute for a fully fledged ambulance, nor can they do anything to speed up a patients journey to hospital. Speed of response is important, but we need to be very careful; targets imposed on ambulance trusts that are expressed in terms of response times and nothing else carry dangers, because they fail to address what really matters, which is the quality of care that patients receive once help has arrived.
Reading about this subject, I have been struck by the absence of useful statistical information. Over the years, there have been various studies relating to the care of trauma patients, but there has never been a nationwide study looking at the overall care of such patients. The Government should seriously consider
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Baroness Thornton: My Lords, I welcome the opportunity to respond to this debate about such an important issue; I agree with the noble Earl on that and I congratulate the noble Viscount on persisting with this debate, which was delayed due to snow. This issue of the treatment of critically ill and injured patients outside hospital and the role of doctors in that treatment, NHS support and otherwise, is critical.
NHS services have to deal effectively with critically injured and ill patients and give them the support and treatment they need, as and when they need it. The job of central government is to provide strategic direction, as the noble Earl said. However, it is surely right that local services determine the best organisational arrangements to ensure that the right services are in the right place at the right time and to provide appropriately for the needs of patients in this area.
What matters is that patients get the right care at the right time, whether that is from a paramedic, an emergency care practitioner, a doctor or another service, and whether that care is provided by the NHS or by partners such as BASICS doctors or air ambulances. It is for the local NHS to commission and manage these services. I shall come on to talk about the framework that is necessary to deliver that, and what we hope will happen.
Noble Lords mentioned London. Its environment presents special and unique circumstances in which those dispatched to treat the seriously ill and injured have to operate. I am pleased to be able to acknowledge that Londons air ambulance is recognised worldwide as having led the way in the treatment of advanced trauma. The London Ambulance Service is also fortunate to be able to call on an extremely well established team of BASICS doctors who possess a wealth of experience in this kind of care; but of course circumstances and demands differ across the country.
Baroness Tonge: My Lords, before the noble Baroness leaves the subject of London, can she explain why there is not a 24-hour service there and why we have to depend on volunteers for part of the 24 hours?
The work of BASICS doctors differs from area to area. I do not pretend that this is a perfect service, but I am trying to explain how we are making progress in this area. We absolutely welcome the invaluable support that BASICS provides in advanced trauma cases.
On the front line we have an ambulance service that deals with more calls than ever before. It is still treating the critically ill and injured more quickly; it is saving more lives. During 2007-08, 77.1 per cent of category Athat is, immediately life-threateningcalls received a response at the scene of the incident within eight minutes. This is the ambulance services best ever emergency response rate. The new call connect method of measuring response requires ambulances to respond, on average, 90 seconds faster than was previously the case. As further evidence of how critically ill and injured people are benefiting, we need to consider that survival rates for cardiac arrest show a year-on-year improvement in the number of people resuscitated after cardiac arrest.
We know that we need always to seek better ways of responding to critically injured and ill patients and the victims of trauma. In this context, we welcome the findings and recommendations of the National Confidential Enquiry into Patient Outcome and Death, or NCEPOD, report of last November. The report made strong recommendations about how the treatment of trauma care could be improved. The Government and the NHS have taken the recommendations to heart. The key recommendation of NCEPODs report is that planning for severe trauma care should be done at a regional level. This allows for the pooling of specialist skills and equipment, to offer patients for whom every second counts the best quality of care available, from specialists in specially designed centres.
There is a relatively low incidence of severe trauma cases in the UK, with the majority of hospitals seeing less than one such patient per week. The question is how to have the best qualified people available on that basis. Surely, it is more important to have more and better qualified paramedics backed up by BASICS doctors. The Government agree with NCEPOD that it is not necessarily the proximity of the nearest hospital or accident and emergency department that matters most in some emergencies, but, as the noble Baroness, Lady Masham, pointed out, the care that patients receive from ambulance staff and paramedics, and the quality of the care that they receive once they arrive at hospital.
Baroness Tonge: My Lords, I am sorry to interrupt. The Minister is being very generous in giving way. Yes, of course, the care that the trauma patient receives at the site of the accident will determine whether they survive. Trauma centres are great, but you need to stabilise the patient as quickly as possible and get oxygen to their brain before you get them to the trauma centre. The Minister is still saying, I think, that this service will be provided by ambulance crews and paramedics, with the help of BASICS doctors. BASICS is a charity. Are we to depend on volunteers to assist the most seriously injured people?
Baroness Thornton: My Lords, I was trying to explain that not every single call-out for every single ambulance requires a doctor to be on board. Is that what the
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Strategic health authorities, as part of the Governments next-stage review, have to set out their visions for improving the provision of trauma care services. I am pleased to say that the majority are planning to set up one or more of these centres. I also welcome the appointment of Professor Keith Willett, the Governments new director for trauma. I have not, in any of my briefings, seen the word tsar, so I certainly do not intend to use it. His appointment comes into effect on 1 April. He has extensive experience in trauma care and medical management. His appointment sends a clear message of intent from the Government on this issue. The noble Earl, Lord Howe, is quite right: we expect to hear more about trauma. Indeed, we need to hear more about trauma.
Two issues deserve special mention. First, the noble Earl, Lord Howe, mentioned research. Research has shown that air ambulances can provide particular assistance in cases where the patient has suffered major blunt trauma, especially in rural areas and where road access is a problem, as mentioned by the noble Baroness, Lady Masham. They can be an effective way of getting better and faster access to hospitals and are valuable in supporting inter-hospital transfer. The department continues to encourage the air ambulance charities and ambulance trusts to work together to agree how both services can maximise their contribution to high-quality patient care. In recognition of the contribution that air ambulances make, in 2002 the Government directed NHS ambulance trusts to meet the costs of clinical staff on air ambulances. That includes, where appropriate, doctors.
Secondly, I welcome the valuable work of those who work for the British Association for Immediate CareBASICSas volunteers. We acknowledge the valuable support that these doctors offer local NHS services and recognise that the availability of the medical advice and assistance that they bring has advantages for some seriously injured patients. However, central government currently has no plans to require the NHS to fund BASICS doctors. As I have already explained, it is for the local NHS to decide how it uses BASICS doctors. I understand that in some places ambulance trusts have clear systems to allow them access to the control room to call on the expertise of BASICS doctors immediately when they are required.
In response to a question from the noble Baroness, Lady Tonge, it is worth noting that some paramedics are now trained to intubate. Various trusts across the country have a cadre of specialist trauma paramedics who have, and indeed use, these skills.
The noble Viscount raised the issue of South Central Strategic Health Authority. This SHA advises that there is no commissioning of doctors outside the hospital environment within its area, but it uses the
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The noble Baroness, Lady Masham, referred to Yorkshire. The Yorkshire ambulance service receives support from a network of volunteer doctors across the county. These medics are affiliated to BASICS, they have specialist training and their skills are particularly valuable. Their 999 communication centres are linked to the BASICS doctors by pager so that they can be called upon when needed.
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