NHS: Doctors — Question for Short Debate

– in the House of Lords at 7:19 pm on 23rd March 2009.

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Tabled By Viscount Falkland

To ask Her Majesty's Government why the National Health Service does not provide doctors to treat critically injured and ill patients outside hospital anywhere in the United Kingdom except London.

Photo of Viscount Falkland Viscount Falkland Liberal Democrat 7:30 pm, 23rd March 2009

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

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

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

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

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

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

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

Photo of Baroness Masham of Ilton Baroness Masham of Ilton Crossbench 7:38 pm, 23rd March 2009

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

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

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

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

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

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

Serious illness often presents out of doctors' hours. It can be very difficult in rural areas for seriously disabled people and people who do not drive to get access to a doctor. Doctors have to cover events such as horse shows, race meetings, rugby games and all sorts of occasions. Organisers of the events have to pay for that, but it shows the importance of doctors being present where there are risks. I think the answer to the noble Viscount's Question is that there is an important need for doctors to save lives, but the NHS cannot afford to do everything. At times there has to be shared co-operation, communication and co-ordination.

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

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

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

"To be effective all processes, including"— acute trauma life support—

"and other components of care of severely injured patient, must be embedded in practice at every stage: the scene of the accident; alerts to the hospital; the journey from the scene to the emergency department; preparations made there; expertise accessible on arrival and at all subsequent stages, including transfer to specialist services ... It is by sympathetically, and analytically, studying where things go wrong that we can learn most".

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

Photo of Baroness Tonge Baroness Tonge Spokesperson for Health 7:47 pm, 23rd March 2009

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

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 victim's 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. They are not allowed to do it now. The difficulty comes when the patient is semi-conscious and needs to be anaesthetised before the tube is put into their windpipe to give them essential oxygen. That can be done only by a fully trained doctor anaesthetist, someone who really knows what they are doing. It is quite a delicate procedure. Then the patient can go to hospital and, one hopes, the right hospital. Sometimes, as we have heard, they will go to an A&E department, where they are assessed and sent on to a specialist centre. Valuable time is lost. The worst scenario is if a doctor is not at the scene of the accident quickly to ensure that the patient's brain gets oxygen. That is the crucial thing.

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 "enquiry" into patient outcome and death, called Trauma: Who Cares?. Incidentally, why is that a confidential "enquiry"; 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 comas—people with all sorts of conditions need oxygen given to the brain during the transfer to hospital—are 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 heaven's 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 Care—BASICS—consists 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.

Photo of Earl Howe Earl Howe Shadow Minister, Health 7:56 pm, 23rd March 2009

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. The financial contribution that the NHS makes, or does not make, to the running costs of those charities is a debate for another day, but I am slightly worried that, when it comes to developing and enhancing air ambulance services, the Government are leaving rather too much to local determination. That point was powerfully made by the noble Baroness, Lady Tonge.

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 patient's 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 such a study. A good deal of the data that we possess has come from TARN, the Trauma Audit and Research Network, which was instigated 20 years ago following a working party report by the Royal College of Surgeons. That database is extremely valuable, but participation in it needs to be rolled out more widely if we are to gain an understanding of where the most serious shortcomings in trauma care exist.

I hope that the Minister can illuminate these issues and give us cause to hope that the concerns raised by the noble Viscount and, indeed, all speakers will be satisfactorily addressed.

Photo of Baroness Thornton Baroness Thornton Government Whip, Baroness in Waiting (HM Household) (Whip) 8:06 pm, 23rd March 2009

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.

Perhaps I should declare an interest. My brother is an ambulance driver in Yorkshire and, I think, is qualifying as a paramedic right now.

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 London's air ambulance is recognised world wide 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.

Photo of Baroness Tonge Baroness Tonge Spokesperson for Health

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?

Photo of Baroness Thornton Baroness Thornton Government Whip, Baroness in Waiting (HM Household) (Whip)

My Lords, it is a 24-hour service. Perhaps I may continue with my remarks to explain what happens.

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 A—that is, immediately life-threatening—calls received a response at the scene of the incident within eight minutes. This is the ambulance service's 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 NCEPOD's 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.

Photo of Baroness Tonge Baroness Tonge Spokesperson for Health

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?

Photo of Baroness Thornton Baroness Thornton Government Whip, Baroness in Waiting (HM Household) (Whip)

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 noble Baroness is suggesting? What you have to do is ensure that ambulance staff and paramedics are as well qualified as they can be. I will talk about their training in a moment. You have to ensure that the best possible care is available as quickly as possible, but clearly that does not include, or depend on, having a qualified doctor on every ambulance crew, unless that is what the noble Baroness is suggesting. Clearly, that would not be a proper use of qualified doctors.

Strategic health authorities, as part of the Government's 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 Government's 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 Care—BASICS—as 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 have 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 BASICS voluntary scheme on occasion. The strategic health authority considered the skills required in the pre-hospital environment and felt that the priority was to expand the capacity of emergency care practitioners, who have an enhanced range of skills when compared with paramedics, for the care of critically ill patients. Paramedics in this region are now able to administer a variety of 40-plus drugs and medications and are also able to perform procedures such as crypto thyroidotomy, chest X-rays and so on, in additional to intubation, infusion and other advanced life-saving skills. That occurs within the noble Viscount's strategic health authority.

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.

The noble Earl, Lord Howe, referred to the new director of trauma, who will be working with the strategic health authorities and PCTs to help them to implement best practice. Professor Willett's priorities will include ensuring regional excellence in dealing with severe trauma. He will be expected to work with each strategic health authority to develop the plans that arise out of the NCEPOD report, Trauma: Who Cares?, and to take forward the next-stage review of my noble friend Lord Darzi.

In conclusion, we believe that the NHS, guided by the outcomes of the next-stage review, is providing a better service than ever before. However, we are not complacent: we know that there is room for improvement. We welcome this debate and the questions that have been raised, and the new director is taking note as noble Lords speak. I am sure that this will not be the last time that we debate these issues.

Sitting suspended.