WITHDRAWAL OF DRUGS & EQUIPMENT FROM THE STAFFORDSHIRE AMBULANCE SERVICE
5th December 2006
Michael Fabricant (Lichfield) (Con): It is a pleasure—in some ways—to be here, and a pleasure, too, to see so many Staffordshire Members of Parliament present. I bring apologies from my hon. Friend the Member for South Staffordshire (Sir Patrick Cormack), who had to be abroad on parliamentary business today.
We have all heard of a postcode lottery in the national health service. Until recently, we in Staffordshire have been the beneficiary of that lottery. We have the best ambulance service in Europe, and until now, a person was four-and-a-half times more likely to survive a severe heart attack in Staffordshire than in the west midlands. Why? Staffordshire ambulance service crews and community first responders arrive quickly to attend to victims, and until now, they have had the right drugs and equipment to apply treatment. But no longer. Life-saving equipment has been withdrawn from emergency ambulances, and drugs and equipment have been removed from community first responders. It is something that all Staffordshire MPs—Labour and Conservative—feared. We warned the Prime Minister and the Secretary of State for Health, and we are now witnessing a tragedy unfold before our eyes.
The tragedy will unnecessarily reduce standards of care in the NHS, and people have estimated that it will cost many lives each year in Staffordshire. If it is not halted, the clock will start ticking with the first death. Let me be clear: this debate is all about saving lives and praising the paramedics and community first responders who are so professional in their work in Staffordshire. However, they are being let down badly by the lack of leadership, the weakness and the unprofessionalism of some of their senior management.
Although Ministers provoked the problem through their merger plans with the West Midlands ambulance service, there have been unintended and avoidable consequences. I shall go further, and say to the Minister that the Department of Health has been professional and consistent in its advice to the management of Staffordshire ambulance service. They have chosen to ignore it, and to risk lives as a consequence. I hope that the Minister will pass on my praise to the health professionals in his Department, whose letters I shall quote from later.
Roger Thayne—the former chief executive of Staffordshire ambulance service, who built it up to become the great service that is now so under threat—and many others estimate that 20 lives or more will be lost unnecessarily in Staffordshire each year, because of confused and bewildered management. They have a lot to answer for.
I intend to expose to the Chamber the web of deception and lies that has engulfed the new management of the Staffordshire ambulance service ever since the Government announced their intention to merge it with the West Midlands ambulance service. Prior to that announcement, Staffordshire ambulance service had been demonstrating the kind of leadership in public care that was the envy of communities throughout the United Kingdom—and overseas.
When Staffordshire ambulance service recognised that most lives were saved in the first five minutes after an emergency, and that it would never be able to secure the resources to provide a rapid emergency ambulance service to rural areas, it set up progressive, community-focused initiatives. They included teaching first aid to children as young as five, and making defibrillators available in local areas. That common-sense approach resulted in the Staffordshire service achieving the UK’s quickest response times and some of the country’s highest survival rates. Cardiac arrest outcomes were about five times better than the national average, and four-and-a-half times better than in the area served by the West Midlands ambulance service.
In a national context, if all ambulance services were as successful as the Staffordshire service was—it is important that I have to use the past tense—the NHS would discharge each year between 4,000 and 5,000 more patients alive than dead. Staffordshire did all that while maintaining costs to the taxpayer which were 30 per cent. lower than the national average. A success story, indeed.
I shall discuss two issues. The first is the drugs that have been withdrawn from community first responders, or CFRs, and the second is the ResQPOD units that have been removed from CFRs, regular ambulance crews and paramedics. One of the most important and successful initiatives developed by the Staffordshire service is the community first responder service. Those local volunteers are highly trained, and they are supplied with the necessary drugs to treat heart attacks, asthma, epileptic fits, injuries due to falls, or serious trauma. They start the treatment that is continued by a community paramedic, who is also based locally, which is in turn continued by an emergency ambulance crew. All CFR work is supported and overseen by a doctor, who is available 24 hours a day and provides instruction over the phone. Often, CFRs reach an emergency first, in those life-saving minutes immediately after an incident.
Why have the new management of Staffordshire ambulance service, in the shape of chairman, Robert Lake, and acting chief executive, Geoff Catling, removed vital drugs from CFRs and life-saving equipment from paramedics and trained volunteers? We can only speculate. They blame the law, the Government and the Medicines Act 1968. However, that is a lie, as I shall demonstrate later.
One possible reason for the removal is that a West Midlands ambulance paramedic, not from Staffordshire, who is a paid UNISON official, first raised the issue of CFRs carrying life-saving emergency drugs and equipment through his concern that paid paramedics and ambulance crews would lose out on overtime and job opportunities. We do not have such problems with industrial relations in the Staffordshire ambulance service, thank God. In any event, Staffordshire CFRs are never used as an alternative to the ambulance service; for all 999 calls, a paramedic and/or ambulance is called out. CFRs simply arrive on the scene more quickly, as they are based in the area; I want to reassure UNISON, a good and constructive trade union, of that fact.
A quick response time is not enough, however. Without drugs and equipment, CFRs cannot do their job.
Mr. William Cash (Stone) (Con): Is my hon. Friend aware of the Coppice Lane estate in my constituency? It is effectively cut off by a railway line, which creates enormous problems, because there are no facilities available with the proper equipment and medical care.
Michael Fabricant: I used to represent Stone, before a boundary change, so I know the area. My hon. Friend is absolutely right. Indeed, there are many other areas like that in rural Staffordshire. At this point, I should like to heap praise on the hon. Member for Staffordshire, Moorlands (Charlotte Atkins) who has been only too aware of that very problem in her own rural constituency.
Why has the change taken place? The excuse given by Lake and Catling for withdrawing drugs and services is that their use is illegal under the Medicines Act. The Act prescribes which drugs can be administered by whom and under what circumstances, such as emergencies. It also outlines clinical governance for the storage and distribution of those drugs. That news first became public when on 17 October, NHS West Midlands head of special projects, Steve Coney, wrote to Members of Parliament and others informing them that all but three drugs previously available to save lives were to be withdrawn. Confusingly, the very next day, Staffordshire ambulance service issued a press release saying that, actually, six drugs remained available.
The press release was supported by correspondence from acting chief executive, Geoff Catling, who wrote to MPs and others. In his letter from the Staffordshire ambulance service, he said:
“Following an initial investigation, I have taken the decision that certain drugs used by our community first responder (CFR) schemes are to be withdrawn...whilst the training of the CFRs is extensive”—
I am glad that he admits that—
“and to a high standard, concern has been raised”—
by whom, we do not know—
“that under the Medicines Act, it would appear that a number of drugs are not eligible for use by lay people under the national legal framework for medicines. Now that the status under the Medicines Act for certain drugs is clear, the consequence is that the Trust can no longer provide indemnity to CFRs who may be operating outside the legal framework of the safe and secure handling of medicines.”
The indictment is clear. He blames the Medicines Act and the Government. He is right that the Medicines Act is clear, but it is not as he misleadingly claims. The use of the drugs is entirely legal—an opinion consistently supported by the Department of Health and the Medicines and Healthcare products Regulatory Agency. I have a letter from Victoria Milnes at the Department of Health’s customer service centre:
“The view of the Medicines and Healthcare products Regulatory Agency is that community first responders are in a similar position to Trust employees if they:
a) are engaged by a Trust to provide emergency response services as part of the Trust's business”,
which they are,
“b) are trained by and subject to the direction and control of the Trust”,
which they are,
“and
c) work on its behalf and are fully accountable to it”,
which they are. The letter goes on to say:
“This means that they can be supplied with appropriate drugs by the Trust without contravening the Medicines Act.”
I have a further letter from the MHRA, the executive agency of the Department of Health.
Charlotte Atkins: Will the hon. Gentleman give way?
Michael Fabricant: I will just quote from it, and then I will give way to the hon. Lady. The letter says:
“The Agency has taken the view that if community first responders in Staffordshire were engaged by the Trust to provide emergency response services as part of the Trust’s business, are trained by and subject to the direction and control of the Trust, work on its behalf and are fully accountable to it, they are in a similar position to Trust employees: i.e., they can be supplied with appropriate drugs by the Trust without contravening the Medicines Act.”
Charlotte Atkins: The hon. Gentleman quoted from a Department of Health letter. After that quote, an additional paragraph mentions the importance of ensuring that
“clinical governance arrangements are sufficiently robust to ensure safe and effective practice.”
Is that not the problem that Geoff Catling and Robert Lake have picked up—the training of CFRs?
Michael Fabricant: That is indeed what they are talking about, and I shall address it shortly, but it too is an excuse and a lie, as I shall point out later. CFRs in other ambulance services with fewer controls than the Staffordshire ambulance service use those drugs. It is an excuse, and the hon. Lady and other Members of Parliament should not be befuddled by excuses. The drugs are used by other ambulance services, and they have the approval of the Department of Health. I shall come to that in more detail shortly, but I am grateful to the hon. Lady, who has been a doughty defender of CFRs, for raising the issue.
Seven drugs have been withdrawn from CFRs: Atrovent, diazepam, Entonox—a gas—glyceryl trinitrate, midazolam, Pulmicort and salbutamol. They are used to treat life-threatening asthma, prolonged and repeated fitting, severe pain, cardiac chest pain, childhood croup and severe pulmonary conditions. In each case, the Medicines and Healthcare Products Regulatory Agency says that it is legal to provide the drugs, as they are administered orally, nasally or rectally and are therefore not covered by medicines legislation.
In fact, where the Medicines Act does restrict use of certain medicines—parenteral medicines, which are administered by injection—there is no bar to anyone using them in an emergency situation in order to save a life. Two such medicines, adrenaline and glucagon, are still being used by Staffordshire CFRs. There is no bar to CFRs using the drugs. Indeed, they are still being used by CFRs with less training in other ambulance services which have fewer protocols for keeping the drugs, including east midlands and Northumbria, where they are still being used to save lives, just as they could be used to save lives in Staffordshire. Who do the Staffordshire management think they are kidding?
In addition to the specific legal restrictions—this is the point raised by the hon. Member for Staffordshire, Moorlands—trusts need to ensure that their clinical governance arrangements are sufficiently robust to ensure safe and effective practice. That includes appropriate logistics as well as internal regulation and audit procedures. However, ever since the CFR programme began, Staffordshire ambulance service has had measures in place to address that—measures more complex and robust than in other ambulance services where the drugs have not been withdrawn. Whenever a CFR administered a drug to a patient, that drug was replaced from the back-up ambulance under the same procedure that paramedics use. It is a simple one-for-one arrangement that worked perfectly well. The details of the drug—its name, amount, batch number and expiry date—were recorded on the patient report form that accompanies the patient to hospital, and the ambulance service permanently retained a carbon copy.
I understand that a more strict and cumbersome arrangement is being devised in Staffordshire, but I know from the CFRs themselves, as I am sure the hon. Lady does, that even though the present arrangement is being used quite appropriately and legally in other ambulance services, CFRs in Staffordshire alone are happy to accept the added burden of paperwork if it means that they can continue saving lives. Let us not forget that they are volunteers who have undergone eight months of training and that many of them are doctors or have medical backgrounds—as I keep saying, they have a greater depth of training than CFRs in other regions, all of whom are allowed to use the drugs—and let us be clear that there has not been a single improper incident with the drugs and that many lives have been saved as a result.
Charlotte Atkins: The hon. Gentleman mentioned that some of the CFRs are doctors. Is it not the case that a doctor would be able to administer all 13 of the drugs?
Michael Fabricant: Yes, but some of the CFRs are not doctors. They get to the scene first. Just as in other parts of the country, they were able to prescribe and give the drugs. They are not being allowed to do so now, and people will begin to die one by one in consequence. I repeat that there has not been a single improper incident involving the drugs during the past few years, and that many lives have been saved as a result.
I move to the question of equipment. As if taking such medicines from the first people on the scene was not bad enough, the new management of Staffordshire ambulance service have also withdrawn from all their emergency response teams, including regular ambulances, equipment proven to save lives in serious heart attack cases. When someone has a cardiac arrest, there are just a few minutes to save their life. Defibrillation does not always work, so cardiopulmonary resuscitation, which I have used, must be applied directly to the heart. I can tell you, Mr. Amess, that it is hard work. It can crack the sternum and break ribs, but compressing the heart manages to circulate some of the blood supply. That circulation is only 25 per cent. of normal circulation, which often is not enough.
ResQPOD is a device that artificially increases the amount of oxygen in the blood, thus getting more oxygen to the brain, heart muscle and other vital organs, and it increases the amount of oxygen that circulates under CPR by about 50 per cent. ResQPOD has been withdrawn, and again, our management friends, Mr. Lake and Mr. Catling, feature in this sad story. They cite safety reasons, but I have spoken personally to Dr. Keith Lurie, professor of internal and emergency medicine at the medical school at the university of Minnesota in the United States, and the reasons given for the decision taken in Staffordshire are spurious.
Let us be clear; we are talking about dead people, those whose hearts have stopped. ResQPOD is a life-saving device, and Lake and Catling—alone it would seem—are claiming that it is not. Yet it is used by other ambulance services in the United Kingdom—although, interestingly, not by the west midlands ambulance service—and by ambulance services in the United States, whose legal system would soon see to it that it was quickly withdrawn from service if there were any doubts about its safety. It is also used in Canada, France, Germany and Scandinavia. I trust their judgment; I do not trust the medical judgment of Lake and Catling.
The future of the LUCAS unit is also in doubt. It is a mechanical device that provides chest compression during CPR and it effectively does the job of a paramedic by compressing the chest at a rate of 100 compressions per minute, which is very difficult to achieve or sustain. Anyone who has tried CPR will know how hard it is to sustain that rate for a minute or two, but the device does it automatically and indefinitely. It has not been withdrawn yet, and I hope that it will not be.
Each year, out of every 1 million people, about 1,000 suffer a cardiac arrest and will receive CPR. Fewer than 50 of those survive if manual techniques alone are used. If ResQPOD is used, the chances of a patient surviving a serious heart attack is doubled. If a LUCAS unit is used in combination with ResQPOD, and only if it is so used, the chances double again. Together the two devices keep blood flowing to and from the heart at 50 to 70 per cent. of the normal rate, which is much higher than the 20 per cent. figure achieved from the use of manual CPR alone. In Staffordshire, an average of 20 lives are saved; they will not be saved next year if the ban continues. That has all come about since plans for regional ambulance services were announced.
I have said from the outset that I want the best for the people of Staffordshire, the west midlands and the UK. I do not mind in principle if services become regional, or even national, as long as the service is, at the very least, as good as it is in Staffordshire. However, because Staffordshire has been consistently at the top of the performance tables for all measures of good service, such as response times and survival rates, it is the regional service that must improve—not the other way round. Lake and Catling say that response times are still tops, and for once I agree with them. That is great, but arriving swiftly at the scene is just part of the equation: without the vital drugs and equipment, paramedics, CFRs and ambulance crews can do nothing.
It is increasingly clear that the new management have an eye on the regional service, with the result that the people of Staffordshire are already beginning to suffer through the withdrawal of life-saving medicines and equipment. The morale of those who work so hard for the people of Staffordshire is already beginning to fall, through no fault of their own. I dread to think how many lives will be lost in Staffordshire when all the hard work they have put in to building a system that works simply evaporates because the regional service will not open its eyes to a common-sense approach. As I have said in this Chamber before, the Minister should be proud of what we have achieved in Staffordshire, and should want to repeat it elsewhere.
Before I close, I shall give you some statistics and an example. Each day since 18 October, when Staffordshire ambulance service decided to restrict medicines, a CFR has been forced to wait helplessly with a patient, waiting for up to 45 minutes before a medicine that they could have administered on 17 October was administered. I shall read an extract from a message sent by “call sign 699”, who is a Brewood CFR group operator:
“job no:- 30/11/06/337 (Staffordshire Ambulance’s 337th incident last Monday), time 17:39, age 83, trauma (shaft femur), (broken thigh bone, near the top, the jagged ends will have been pulled by her thigh muscles so they overlapped, shortening the leg by about three inches—making diagnosis easy and the pain terrible) drug required:- entonox (gas and air—50 per cent. nitrous oxide, 50 per cent. oxygen—it would have dulled the pain enough to have allowed the ambulance crew to move her onto the ambulance as soon as they arrived; instead there was a further delay of about ten minutes while they set about dulling the pain”.
That drug could previously have been administered by CFRs and it has been unilaterally withdrawn by the Staffordshire ambulance service, even though it is in use by other CFRs in other parts of the country. The message continues:
“time for back up—14 mins (not bad: imagine an accident like this happening up in the Moorlands in a blizzard when the air ambulance can’t fly and the land ambulance is stuck on the Leek to Buxton road. How long would the poor old lady have had to wait for pain relief then?)”
That was sent by a community first responder called Ann.
It can easily take an ambulance 30 minutes to reach some areas—longer in winter—and we should note that the air ambulance does not fly at night or in bad weather. It is telling that no one from the West Midlands strategic health authority or the West Midlands ambulance service has visited a Staffordshire CFR group to see how it operates or to see the nature of the terrain. CFRs and community paramedics get into remote areas and deliver life-saving support—the Minister should note that it is a success story. However, although they are still the first on the scene of an emergency, they are no longer able to help. In the worst cases, they will be forced to watch someone go into cardiac arrest before they can attempt to help, knowing that before vital medicines and equipment were removed by the Staffordshire ambulance service’s management, they could have prevented it from happening.
The merger or “partnership”, as it is called, between the Staffordshire and the West Midlands ambulance services is developing into one of our worst fears. No sensible explanation has been given as to why, in the build up to the merger, drugs and equipment still in use in other ambulance services in England and elsewhere were suddenly considered to be illegal or dangerous for use only in Staffordshire. The action by Staffordshire ambulance service to withdraw CFR drugs and ResQPOD is down to a major clash of cultures and, as it is neither practicable nor permissible for an ambulance service to operate different standards in a region, it is easier—and, I guess, cheaper—to restrict the medicine and equipment that Staffordshire’s emergency medical services carry than it is to train its colleagues in the west midlands.
It is disheartening to note that, perhaps uniquely, by merging the two and ignoring best practice there is a real risk that clinical care will be reduced and operating costs and deaths will go up. The question that I put to the Minster is this: if community first responders and paramedics cannot treat emergency patients with appropriate medicines and equipment, why is the ambulance service still dispatching them? If that is being done to meet response time targets, it is surely a despicable misuse of volunteers that cheats patients because, without the vital drugs that have been withdrawn, the CFRs can do little when they arrive.
I started the debate with a figure. People in Staffordshire are nearly five times more likely to survive a heart attack than the national average. The people of Staffordshire in such circumstances are now five times more likely to die. I urge the Minister to use all the power of his office to sort this mess out because he will have a much more serious debate on his hands as soon as the first life is lost that could have been saved. The clock starts ticking with that first unnecessary death. I, for one, do not want that debate to be necessary.
