Even after 11 years, one of the joys of this job is that, every now and then, I come across an issue about which I know nothing. Somebody comes into my surgery, gives me a briefing and I go away thinking, "That's extraordinary. I had no idea that was going on." Specialist care for seriously injured people is such a subject.
A few months ago, a couple of my constituents—Phil Hyde and Ewan McMorris—briefed me about the work that they did. They said that the subject that they wanted to discuss was pre-hospital care, and I assumed that they would talk about rehabilitation, drugs, therapy or something that would prevent people from going into hospital. However, as the conversation developed, it became clear that they are providing an enormous specialist service, particularly in Hampshire. This morning, I shall go through some of the facts and figures about the service that they provide and consider how the Government can do more to support such work.
In essence, the role of those people is best described as taking the skills of an accident and emergency department out to serious accidents and injuries—most typically, a road traffic incident. The service they provide is different from that of the ambulance service, paramedics, and first responders, who are now quite commonplace and whom many of us will have in our constituencies. The philosophy behind immediate care is the prevention of the deterioration of a patient in those first critical minutes between the time of an accident and before they are taken to the A and E department.
I had assumed that such a critical service would be part of the NHS, but it is not. I was surprised to discover that the service is provided by volunteers, charities and a couple of organisations that work closely in the field. The British Association for Immediate Care—BASICS—and the Mid-Anglia General Practitioner Accident Service, which is an emergency medical charity, are the major players in the service. My amazement at the service they provide, coupled with my astonishment that it was not centrally funded, meant that I decided to probe the matter and do a bit more work on the subject.
I am delighted that my hon. Friend Sandra Gidley is here because I know that she has met the individuals concerned and has taken up some of the issues on their behalf. In Hampshire, we are lucky to have the service that they provide. On average, they attend an incident between two and eight times a day. In the Hampshire area, there were 1,200 requests a year for basic doctors and, through the work the charity does and the volunteers that it has, it is able to attend 750 of those calls. There is a big demand, but the worrying statistic is that although it is good that we have volunteers, they are not able to meet all the calls made on their watch.
The work involved often relates to traffic incidents, and we know that, on average, some 3,460 traffic fatalities take place each year. We also know that trauma is one of the big causes of death in this country. The latest figures suggest that trauma remains the fourth leading cause of death in western countries, including this country. Clearly, much work needs to be done to try to reduce the number of deaths. For each trauma death that takes place there are two survivors, who often end up with a serious and permanent disability. Anything that we can do to reduce the disabilities and injuries from which such people suffer will have a big impact on their lives.
The model that we have in this country differs from the rest of Europe. For example, Germany takes a different approach to trauma care. There is a nationwide network of helicopters and road vehicles that can, in 95 per cent. of cases, get a skilled doctor to the scene of an incident within 15 minutes. We even trail behind America in relation to trauma care. The UK mortality rate for severely injured trauma patients who are alive when they reach hospital is a staggering 40 per cent. higher than that of the US.
We know that the level of trauma-related deaths is high in this country, and that other European countries and America are able to tackle the problem better. We also know that, despite the various forms of support provided by ambulances, paramedics and first responders, there is still a desperate need to have skilled consultants and doctors who are able to get out to the incident. In Hampshire, although demand for the service is high, it is funded by charities and good will.
Why is it so important to have specialists as part of the service, and what do they do that is different from first responders and paramedics? First responders would be the first to acknowledge that they are not fully medically trained and can in no way replicate the work of a specialist doctor in A and E. It is also the case that, despite the wonderful work that paramedics do, their degree course lasts just three years. Let us compare that with the training required to be a consultant. Typically, a consultant in A and E would get five to six years at medical school and then a structured 12-year training programme before becoming a consultant. That is the level of skill and knowledge required to treat the most severe incidents of trauma.
The particular specialist skill needed relates to the airways and breathing of patients who have had severe head injuries. Paramedics are not trained to clear the airway or use the necessary drugs and anaesthetics in the treatment of those injuries. In many cases, paramedics are legally prevented from doing so because they are unable to administer the drugs. All the evidence that I have seen suggests that the critical area that an individual needs to have treated at an incident is around the airway, and that anaesthetics and drugs need to be issued. None of those who currently attend incidents are able to treat that specialist injury. However, the specialist consultants from A and E departments can do so, and we are trying to ensure that more of them can carry out that particular work, often at the roadside.
A fair bit of work and research has been done on the subject. The most recent report was in 2007 when the National Confidential Enquiry into Patient Outcome and Death produced a report entitled, "Trauma: Who Cares?" The report takes a general look at how we handle a situation when there is an accident leading to trauma, and considers what happens in the first few moments after an incident. It states:
"The current structure of prehospital management is insufficient to meet the needs of the severely injured patient. There is a high incidence of failed intubation and a high incidence of patients arriving at hospital with a partially or completely obstructed airway. Change is urgently required to provide a system that reliably provides a clear airway with good oxygenation and control of ventilation."
The report highlights the particular specialist skills needed at the scene of an accident. In the study, NCEPOD produced an analysis stating that 60 per cent. of patients whom it looked at received a standard of care that was less than good practice. It also states:
"Many of these clinical issues were related to the lack of seniority and experience of the staff involved in the immediate management of these patients."
Again, the critical issue is seniority and people having the skills to tackle breathing and airway problems.
It is not just NCEPOD that has looked at the issue; the Royal College of Surgeons has also raised concerns in a number of studies. Initially, in 2000, the college called for defined trauma systems comprised of major trauma centres to be established in each region. It describes—in its words—
"the lack of political will" to tackle the issue. It revisited the subject in 2006 and reported little progress or improvement. Its analysis is that the likelihood of dying from injuries has remained static since 1994 despite great improvements in trauma care, training and education. There are not many areas of the health service in which things have remained static since 1994, certainly under the Labour Government—I welcome some of their investments. With many of the indicators, one can see that the advancement of knowledge has been matched by improved outcomes, but this area has remained static since 1994.
Last night, the RCS e-mailed me with a further update on the issue, in which it raised more concerns. It welcomes the fact that volunteers and charities are putting provisions in place throughout the country, but says that coverage is patchy. It describes a postcode lottery and says that there is great inequality in access to and provision of pre-hospital critical care. As a consequence, there are preventable pre-hospital and early-hospital deaths that could have been averted had there been access to appropriate services.
It is troubling that the RCS is saying that we could save lives if we had that kind of system in place across the country. In its note, it estimated that a national system of 24-hour access to specialist physicians who could go out to incidents would probably require an additional 200 specialist practitioners, who would need to be funded. I do not have more accurate figures than that estimate, but if those are the kind of figures involved and if it would have a dramatic impact by cutting the number of deaths, as the RCS says and as other evidence suggests, it would be a small price to pay.
Air ambulances are critical to the ability to save lives after a traumatic incident; however, there are contradictions. I understand that, in London, daytime provision of the air ambulance is centrally funded, but that the evening service switches to charitable funding. There was a debate on air ambulances in Westminster Hall in February for which the RCS did a lot of work. It said how important the role of air ambulances is, but it was extremely concerned that it is left to charitable trusts and individual primary care trusts to fund them. The RCS argues strongly that it is excellent value for money to have an air ambulance.
Another issue that the RCS has raised is the provision of helipads close to accident and emergency departments. There are many examples—including one in Southampton, close to the constituency of my hon. Friend the Member for Romsey—of the ridiculous situation in which the air ambulance is able to get to the scene of a trauma quickly, but is then unable to land near the hospital and has to land a six or seven-minute ambulance journey away from it, so an ambulance has to go to the air ambulance and bring the patient to the hospital. After the air ambulance has provided such a quality service, having got to the scene quickly, it is enormously frustrating to the professionals involved that an additional journey is needed at the end.
I am sorry to interrupt the hon. Gentleman's flow, because he is being extremely eloquent in showing how much he cares about this important issue. I congratulate him on securing the debate. Is he aware that when the new Queen's hospital opened in east London, with a specialist neurosurgical centre, the local council placed restrictions on the landing of air ambulances delivering patients at certain times of day? That was an unhelpful interpretation of the balance of inconvenience by the various players in that decision.
I was not aware of that, and I find it extraordinary that a local council representing potential patients would take that decision. Certainly, my conversations with the chief executive of Southampton hospital suggest that he would not have that kind of difficulty with Southampton city council. He thinks that the population would strongly welcome hearing the sound of a helicopter and would find it reassuring.
I have written to Mark Hackett, the chief executive of Southampton University Hospitals NHS Trust. He is keen on having a helipad, but pointed out that funding for it is not available and that there would have to be some sort of public appeal to raise money for it. Given that we are talking about something that could save lives, does my hon. Friend think it right that local members of the public should have to dip into their pockets yet again?
I had a similar conversation with Mark Hackett, who told me that the cost, on its figures, would be about £1 million. He hoped that it might be possible to reduce that cost by putting a helipad on top of a building and incorporating that into ongoing rebuilding at the hospital site. I am no engineer or scientist, but one would think that reasonably easy to achieve. It is breathtaking that such a service should have to depend on charity in today's modern world, particularly as it would cover a region with a radius of about 150 to 200 miles. It would provide a quality service covering the Isle of Man and going through to Dorset, which is an enormous area. One would think, therefore, that it would attract public funding.
It is not for me to tell any of the three political parties what would be an eye-catching issue at the next general election—I am not standing at the next election, so I do not mind too much—but I should think that any party that commits to introducing 10 helipads across the country to ensure that individuals can get straight into an accident and emergency department would have a simple, popular message with a particularly low cost. It is extraordinarily odd that we leave the funding of air ambulances and their work to the good will of volunteers and charities. I hope that the Minister will comment on that.
Four, five, six or seven—anyone is entitled to put forward the policy, but it would be wonderful if the Minister prevented other parties from doing so by announcing something today.
Let me address what is the best way forward with funding. I totally understand that there are demands on Government funding and I am reluctant to say to a Minister, "Come on, cough up," because so many areas have to be funded. I know from parliamentary questions on this issue that the Minister and his colleagues have said, "Look, fantastic work is being done and we totally recognise that this is providing a real benefit to the health service, but it is for local PCTs to decide whether to fund it." That is a cop-out, because we know the pressures that local PCTs are under. Is it right to say that we are going to leave it to the lottery of whether a PCT is able to support such work? People throughout the country—certainly my constituents and, I am sure, those of other hon. Members—want the reassurance that they will get the best-quality support if they are involved in a major trauma anywhere in the country, but that is currently left to good will and chance.
I hope that the Government will consider this issue further and do more work on it. I am encouraged by some of the statements that have come from Ministers so far, who have at least acknowledged that there is more work to do. Lord Darzi said:
"We have taken on board the recommendations of NCEPOD, not necessarily just regarding pre-hospital admission. We also need to have, and define for the first time, dedicated regional trauma centres. It is the one area where there is clear evidence that centralisation of services, with adequate competencies at the site of receiving hospitals, will significantly impact on the quality of care."—[Hansard, House of Lords, 7 January 2008; Vol. 697, c. 630.]
I could not agree more and I hope that the Minister present agrees with his colleague. With that in mind, I ask him to confirm whether he plans to meet the authors of the NCEPOD report. In a written answer in April, he told me that officials were arranging for a further meeting to take place, so I hope that progress has been made with people's diaries; indeed, the meeting may have taken place.
According to a written answer last year from one of the Minister's colleagues, who has moved on to the Home Office, the Government acknowledged the work of the RCS in this area and were hoping to do more work and have meetings with it. It would be helpful to know whether that work has been done and whether the Government have made an assessment of the RCS reports on trauma.
I was amazed to discover that the whole area of specialist trauma response did not exist as part of the NHS. Having met the surgeons involved, I am convinced that, despite the good work of paramedics, the ambulance service and first responders, there is a very big gap—the ability of high-quality experts with high levels of training to reach the scene of an incident quickly and provide the drugs, skills and airway support that definitely could, based on studies done so far, save lives. Linked to that is the question of a decent, funded air ambulance service. We need to put the two elements together. If the Government were prepared to move on this and to put some funding in—not necessarily fund the whole project, but put in some match funding—we could make a significant difference to the number of people who are dying unnecessarily in traffic accidents and as a result of other serious injuries.
I just want to add a footnote to the excellent speech made by Mr. Oaten—my parliamentary neighbour. As you may have seen, Dr. McCrea, a high percentage of Hampshire MPs are present.
I pay tribute to the work of Dr. Phil Hyde and the team in Hampshire for raising the profile of this issue as well as providing the help that the hon. Gentleman described. Like him, I was not aware of the service until my constituent, Dr. Louisa Chan, who lives in Whitchurch, wrote to me. She is one of 19 volunteer doctors and one consultant nurse in the county who act as volunteers working for BASICS—in her case, after doing 56 hours of full-time work for the NHS. She uses her own car with a blue light in responding to call-outs. As the hon. Gentleman said, at the moment, the team can respond to about half the number of call-outs. Of course, they are not called out every time that an ambulance is summoned; they are called out only to the more serious emergencies where their skills could make the difference between life and death. I pay tribute to those volunteers. They were very active following the train crash at Ufton Nervet a few years ago; they were on the scene very quickly.
I want to put this issue in a slightly broader context. The hon. Gentleman touched on the fact that one could argue that this is not the only service that ought to be mainstream NHS but is slightly at arm's length from it. I suppose that the best example is the hospice movement, which one could argue ought to be mainstream NHS. It started off in this country totally independent, run by voluntary organisations, but it is now moving more towards the mainstream NHS; the hospice movement is receiving more support. In Hampshire, we have fantastic hospices: Naomi House, in the hon. Gentleman's constituency, and the Countess of Brecknock hospice and St. Michael's hospice in my own. That is an example of a service that started outside the NHS but is gradually being absorbed into the bloodstream, if I can put it in that way.
The other example, which the hon. Gentleman touched on, is the air ambulance, and it is quite a good parallel with the BASICS service. Until last year, the only local air ambulance service was the one in Thames valley, which I do not think has ever received a penny of public money. We now have our own in Hampshire—the Hampshire and Isle of Wight air ambulance—which, again, I think receives no public money at all. One could say that that is slightly odd. The police have helicopters. No one has ever argued that the police should have a whip-round for police helicopters. They are an integral part of the police service, but specialist trauma response is another emergency service and, for some reason, its helicopters have to be funded in a totally different way. It is not immediately clear why that should be so.
Then we have BASICS, the service to which the hon. Gentleman referred. One could argue that the case for absorption of that service is stronger. With hospices and helicopters, there is something visible for which people can raise money, but for this service, there is nothing visible at all. It is an unseen part of the service. Therefore, one could argue that the case for total absorption and integration is stronger. It is very difficult to say that it is an acceptable risk for patients to rely on off-duty volunteers, possibly to save their lives.
I am sorry to intervene so soon. I am grateful to the right hon. Gentleman for his speech on this issue. He reminds me about the ridiculous situation in which some consultants are on duty, operating and working in the accident and emergency department, waiting for emergencies to come in, and their pager goes off, asking them suddenly to switch to become a volunteer and go out. They cannot do so, because they are working in the hospital, and they have to wait for the patient to come in, knowing that if they had been able to go out as a volunteer, they perhaps could have helped to save a life. What better example is there of the fact that the service should be integrated?
There probably is no better example, and the hon. Gentleman makes the point very well.
Last year, the Hampshire service received the Queen's award for voluntary service. I commend it for that. The hon. Gentleman referred to the National Confidential Enquiry into Patient Outcome and Death, which highlighted the inadequacy of out-of-hospital care. It said:
"The current structure of pre-hospital management is insufficient to meet the needs of the severely injured patient."
I agree. It seems to me that the objective should be to integrate the service that the hon. Gentleman has described into a properly funded pre-hospital service, with doctors and paramedics working together as a team.
The debate calls for a ministerial response, and I am delighted to see the Minister in his place. He can say one of a number of things. First, he could say, "These are wonderful people. I applaud what they do, and I would like to provide this life-saving service as part of the mainstream NHS, but the resources are not there, so we will carry on as we are." Or he could say, "The case has been made. We recognise that, in most other countries, this service is an integral part of a national health service. We accept the case. We will make this a priority, and either move ahead with earmarked additional resources or ask people to do it within existing budgets." Or I suppose that he could say that he wants to reach the same destination by another route; he wants progressively to upskill the paramedics, reduce the call-out times, put better equipment in ambulances and implement similar solutions. I am not sure whether that would achieve the same objective. The paramedics are fine. For the average call-out, they have the necessary skills, but as the hon. Gentleman said, they simply are not trained to the level of doctors.
The Minister might like to respond to this point. The new GP contract contains a provision for a national enhanced service for immediate care, but as I understand it, almost no primary care trusts have commissioned one, so there is a provision, but it is not being activated. This is what we need to know from the Minister. What is the philosophy? What is the policy? Should the service be a mainstream part of the NHS? If so, how will we get there, and as the hon. Member for Winchester said, who will pay for it?
I have a final point about the landing site in our area. The paradox at the moment is that, when someone called out under BASICS gets to the scene, there is almost always an ambulance there as well. If an air ambulance is summoned and takes the patient to Southampton, they then have to go by ambulance to the hospital, as the hon. Gentleman explained. The same ambulance that attended the initial incident then goes to the helipad, so there is no gain in time at all from using the helicopter. Given that paradoxical situation, there is an urgent need to make some progress with a more accessible helipad for patients who are taken to Southampton hospital. I am sure that the Minister will respond as sympathetically as he can, and I commend the hon. Member for Winchester again for raising the profile of this important but neglected subject.
First, I must declare an interest: my son is a consultant neurosurgeon.
I congratulate Mr. Oaten on securing a debate on this important issue. He raised some interesting points. We are fortunate today to have an excellent Front-Bench team, and I am delighted to see the Minister in his place, as I know him to be a caring man. The Government have invested much more in health over the past decade, and I congratulate them on that. However, our constituents do not see a proportionate improvement in health outcomes. We are debating an area in which a little extra spending might give results that people would welcome; I ask the Minister to consider that point.
The hon. Member for Winchester mentioned the different approaches taken by various countries, and we clearly need to review the way in which we provide immediate, on-the-spot care for trauma patients. The hon. Gentleman focused on the first few moments of care. I want to extend that to the first few hours. He mentioned the importance of breathing, clearing airways and similar issues, but I want to focus on head injuries.
Research and experience indicate that there should be no more than four hours between injury and operation if there are expanding mass lesions, such as extradural or acute subdural haematomas. Only 20 per cent. of patients with severe head injuries are treated within those four hours. The problem is not the one hour leading to the CT scan. That is usually met; the response is pretty good. The problem is largely with the inter-hospital transfer—from the hospital that first receives the patient to the specialist hospital capable of dealing with severe head injuries. That is where the problem lies.
The ambulance service and the hospital management team probably consider that, because the patient is already in hospital and in a secure and safe environment, the need to move the patient to another specialist hospital within the four hours is not so important—the priority is lost or diminished. That perception is one reason why the four-hour limit is not met in 80 per cent. of cases. That should be a top priority. If that limit can be met, the outcome for the patient is so much better. However, when it is not met, the outcome becomes worse as time goes by. Many patients die who could otherwise have been saved; and others suffer severe and permanent disabilities who otherwise would not suffer them. Although it is important to treat a collapsed lung, once the patient is in hospital it will not kill them. However, a head injury can kill or cause permanent damage. We need to focus on that specific but small issue. I am sure that the Minister is listening carefully.
A good development that the Government are pursuing is the specialist trauma centre. Patients suffering multiple traumas are taken there in the first instance rather than to a general hospital. That is extremely helpful, because it does away with the inter-hospital transfer. The four-hour limit is more likely be met, and the outcome for patients with severe head injuries and other traumas will therefore be much better. I welcome and support the Government's move on specialist trauma centres.
The hon. Member for Winchester spoke of funding, and I shall follow him. One reason why the UK Independence party wants to repatriate the £15 billion cost of our membership of the EU is to invest more in specialist services, such as immediate trauma care and health care generally. That is another sound UKIP policy.
I congratulate my hon. Friend Mr. Oaten on securing this debate. I have been trying to secure a debate on the subject.
My hon. Friend mentioned Dr. Phil Hyde. Dr. Hyde has also spoken to me. He is clearly passionate about the subject, and there is a real issue over patient safety. I was taken aback and horrified by what I heard in my conversation with him. Before that meeting, despite shadowing ambulance teams on a number of occasions, I had no inkling that, if I were to be seriously injured in a road traffic accident, my prognosis would be severely affected by whether a voluntary doctor happened to be available. That is scandalous.
The 2007 report by the National Confidential Enquiry into Patient Outcome and Death entitled "Trauma: Who Cares?" has been mentioned. It concluded that the current structure of pre-hospital management is insufficient to meet the needs of the severely injured patient. It said that there is currently a high incidence of failed intubation and of people arriving at hospital with a partially or completely obstructed airway. It went on to say:
"Change is urgently required to provide a system that reliably provides a clear airway with good oxygenation and control of ventilation. This may be through the provision of personnel with the ability to provide anaesthesia and intubation in the prehospital phase or the use of alternative airway devices."
That was highlighted as something that needed to be addressed by ambulance trusts, but it is clearly not happening.
Research shows that patients who die from severe injuries often do so within the first hour after the accident. In the United Kingdom, that hour has usually passed by the time the patient reaches hospital. However, sending a BASICS doctor to the scene of an accident is the nearest one can get to sending the hospital to the patient. BASICS doctors will often perform a specialist procedure, known as rapid sequence intubation, to help to stabilise the patient. Once the patient is stabilised, the doctor will be able to judge which is the best hospital for the patient.
Bob Spink mentioned the specialist trauma centres that are being introduced and said that the outcome for patients will be much improved if they can be stabilised and taken to an appropriate specialist unit. If there is no doctor on the scene, such patients suffer a double whammy. They will not have been stabilised at the scene, so it is often decided to take them to hospital quickly, but the nearest hospital may not be the most appropriate. We all know that some hospitals excel at certain aspects and some at others. Many patients are therefore not given the greatest chance of recovery.
As someone who has probably overdosed on episodes of "Casualty", I was surprised to learn that accident and emergency consultants are not generally in the business of donning hard hats and bright protective clothing and going to the scene of accidents. I asked, "Isn't that what happens?" I was told that they could not leave the casualty department, although some are BASICS doctors in their spare time. Not everyone who works in the casualty department is suited to working on the road.
In the casualty department, there is plenty of light, the equipment is where it is needed and there is space to operate on the patient. At the scene of a car crash, one has to work with the noise of the machinery and the fire engines in a confined space; it is a completely different environment. I understand that not everyone can operate easily under those conditions. Those who do so are a special breed.
Most of the doctors who provide the BASICS service are fully employed in the NHS—sometimes in A and E, as I said, but often in other disciplines, such as intensive care or surgery. BASICS doctors are particularly valuable in providing complex airway management procedures and stabilising patients in a critical condition.
BASICS doctors work closely with the ambulance service when a multi-agency response is required locally or when additional skills and qualifications are needed. They are usually called when a paramedic decides that he or she does not have the training to deal with an incident. The paramedic who arrives at the scene will often call the BASICS doctor, although in the case of a fatal crash, the control centre will sometimes call them out.
An industrial accident involving a worker who has become trapped in machinery is a good example of what happens. The ambulance service would work alongside the fire service to co-ordinate the rescue. BASICS could supplement the skill set available at the scene by providing a medical doctor with the necessary extra skills. If necessary, the doctor may use a surgical procedure to extricate the patient, although that is obviously a last resort.
I know Hampshire best, and it is where I have the best figures from, so I will use it as an example. As Sir George Young said, the county has 19 volunteer doctors and one consultant nurse for a population of more than 1 million. Those BASICS staff work on their own time and carry a pager that is activated by the ambulance control in Winchester. Once paged, they must travel to the scene of the accident in their own cars, using blue lights and sirens. BASICS staff must provide not only their own transport, but all their own equipment. It can cost up to £25,000 fully to equip one of those doctors. Frequently, some of the money comes from the doctors' own pockets, although staff do not really have much time for fundraising between doing their day job in the NHS and volunteering in their spare time.
Let me give a few statistics. In Hampshire, BASICS doctors are usually called out between two and eight times a day. There were about 1,200 calls last year, and BASICS doctors managed to attend 750 of them. We can only hazard a guess about what difference they might have made in the 450 cases in which no such response was possible.
Perhaps I can give a snapshot of what the BASICS staff do. In January, they responded to 58 calls, although I do not know how many they were unable to respond to. Two thirds of the calls that they responded to involved motor vehicle collisions. The others involved falls, burns and machinery accidents. In 16 cases, the doctor was required to give anaesthetic drugs. In 10 cases, they provided advanced wound management and life-saving minor surgery, as well as injecting drugs into the aorta. I mentioned the importance of admitting patients to the most appropriate hospital, and 26 of the 58 patients had their destination altered, because of the knowledge and expertise of the BASICS doctors.
Things vary throughout the country. In Sunderland, which has one of the best survival rates, the death rate for people coming into the unit is 2.9 per cent.—half the national average. Bosses from City Hospitals Sunderland NHS Foundation Trust say that that is due to high investment in staff and facilities. Interestingly, the trust has also introduced a new trauma response team, and the figures speak for themselves.
It might also be worth mentioning London, which seems to have more advanced provision than many areas of the country. Specialist trauma teams are funded by, and travel with, the London air ambulance service. As my hon. Friend the Member for Winchester said, however, the air ambulance stops flying at night for some reason, and some of the provision then becomes voluntary. I am told that there are also only 15 BASICS doctors in London, covering a population of 8 million people. The moral of the story appears to be that, if someone is going to be involved in a serious accident, they should make sure that it happens in London during the day, so that they have the best chance of receiving specialist care.
Clearly, there are many political priorities, and I can understand why there is not a huge patient lobby banging on the door to raise this issue. The Government could therefore quietly ignore the problem or dismiss it with the old chestnut that, "This is nothing to do with us. We're trying to get these decisions taken locally." However, we need to take a more strategic approach to determining which specialist services are provided and where. People do not have accidents along primary care trust boundaries, and the issue is a real example of a postcode lottery—I hate using that term, but I have never seen a better example of one.
The fact remains that investment in this volunteer service can save money in the long term, because patients will have better outcomes and be less likely to need intensive post-trauma support packages or access to other benefits. The Government presumably have an interest in keeping their citizens safe and well.
I want now to summarise the national inquiry. The inquiry noted that the standard of care received by 60 per cent. of patients was less than what was judged to be good practice, and deficiencies were identified in organisational and clinical aspects of care. Difficulties were highlighted in identifying patients with an injury severity score of more than 16. Again, if such things are done properly, it will optimise the use of precious resources. Problems were identified not only with immediate pre-hospital care, but with trauma team responses generally and with the seniority of the staff involved once someone actually got into hospital. People were frequently not seen by a consultant within the first 12 hours, even though they were probably among the most injured patients in the country. Problems were also identified with immediate in-hospital care and the provision of suitably qualified staff at all times of day and night.
The report made a number of recommendations. It identified the need for designated trauma centres, and I acknowledge that we have had some movement on that. It also asked for a verification process to be developed to guarantee the quality of care. The report referred to the pre-hospital management of airways, which I have mentioned. It stated that a trauma team should be available 24 hours a day, seven days a week. It also noted that a consultant should be the team leader for the management of severely injured patients. The report also made recommendations about the nature of CT scanning once people were in hospital.
As has been highlighted, this is not a new problem. One of the most depressing things that I read was that the Royal College of Surgeons had looked at this issue in 1988 and 2006 and said that there had been no progress. It noted:
"most of the improvement in the outcome of these patients occurred prior to 1995, with no further significant change occurring between 1994 and 2000."
That is quite a damning indictment of what we are doing—or not doing.
Also pertinent to the debate is the NHS emergency planning guidance, which contains principles for effective emergency health planning. The chief executive of each NHS organisation is responsible for ensuring that it has a major incident plan in place. Given what we have heard about trauma response, it is somewhat ironic that that major incident response could apparently also hinge on the availability of volunteer doctors.
The situation that I have outlined is not sustainable in the long term. I hope that the Minister is sufficiently persuaded by what he has heard today to commit to improving services. Put simply, if any of us or our constituents ever need trauma care, we surely deserve the best.
Let me declare an interest at the outset as a trustee of the new Essex and Herts Air Ambulance Trust and a patron of St. Francis hospice in my constituency. I will say a little about hospices later.
I congratulate Mr. Oaten on his passionate and articulate speech on this important subject. He raised so many issues in his short contribution that it will be difficult to address them all, but I hope that the Minister will deal with many of them and perhaps some of those raised by other hon. Members.
My right hon. Friend Sir George Young spoke about the hospice movement. There is an obvious link between that movement and the sort of voluntary medical care that we have been describing. My right hon. Friend alluded to the fact that the hospice movement is being drawn closer to the NHS, because of their funding streams; but one of the biggest concerns of my local hospice is that the tail is starting to wag the dog. The NHS is starting to fund it and tell it how to provide care, which is completely against the way that the hospice movement was set up. That relates to some of my concerns about the topic that we are debating.
I, like many other hon. Members, have been contacted by Dr. Phil Hyde of BASICS. I am due to meet him in the next few weeks. I have also been contacted by other groups, such as the Sussex and Surrey immediate medical care scheme, and by Dr. Alan Jones at Mid-Anglia General Practitioner Accident Service—another excellent voluntary organisation. One of the most telling things that the hon. Member for Winchester mentioned was the figure of 750 responses to 1,200 requests. That is a fantastic response for a voluntary organisation; but as a former member of the emergency services who has attended road traffic accidents while we waited for response units, I know that it is a frightening experience for the patient and the other emergency services when they do not know who is coming and whether there will be a response. As Sandra Gidley said, that is not new.
I have been out of the fire service for some 17 years, but in the 11 years that I was in it, I never once trained alongside an ambulance paramedic crew. We do not train together. What goes on out there is frightening. When people arrive at an incident, the training clicks in, but very often it is individual training. I was out recently with a crew from the London ambulance service, and I asked them when they last trained with other emergency services—the police or particularly the fire brigade, with whom they would go to RTAs. The gentleman I spoke to had served 20 years, and he had not trained in that way. I asked my own local fire crew, green watch at Hemel fire station, which is a joint station with the ambulance trust, "When was the last time you trained with ambulance paramedics?" and was told, "We don't sir; we ask but it does not happen." The pressure of time, particularly on the ambulance service and paramedics, is crucial.
An aspect that we need to examine, which has been alluded to in the debate, is best practice, if that is what we want to call it, and the lack of a defined system throughout the country. I, like the hon. Member for Romsey, do not like using the term "postcode lottery" for the pot luck situation in which where people live affects the emergency services that they may need to use, but I do not know a better way to describe it. People in one PCT are likely to get better care than people in others. I, too, have been to Sunderland and Newcastle, where they have a wonderful system, but I have also been to other parts of the country where things are much more difficult.
It is best to listen to the experts as well as to politicians. A recent report by the Royal College of Surgeons shows that a third of all deaths from trauma are avoidable. That is in the 21st century NHS, with £110 billion going into it, and the vast majority of those cases involve people under the age of 44. The largest cause of death of people under 44 in this country is trauma—road traffic accidents. Our lifestyles mean that those incidents will occur. So, surely, we should have a level playing field across the country for the care and expertise to be provided by the emergency services when they arrive.
I have also read reports that say that consultants are needed to lead trauma teams at as many incidents as possible. The problem is that, as many hon. Members know, we have a shortage of consultants, particularly accident and emergency consultants, and as those pressures mount, it is very difficult for any PCT or acute trust to decide to take a consultant out of A and E and send them to an incident. I should very much like to discuss during this debate how we could increase paramedics' skills. I fully admit that in the past decade the skills of our paramedics, who serve us wonderfully well, have hugely increased.
I was a paramedic in Her Majesty's armed forces many years ago. A paramedic means something completely different in the armed forces. I left the Army in 1982, with three years' training as a paramedic for use on the streets of Northern Ireland, where we dealt with huge problems, with airways in particular. We were trained in tracheotomy. The most basic Army paramedic had done a tracheotomy course before being deployed with troops. When I left the armed forces and joined the Essex county fire and rescue service, I was asked to take a first aid course: I had three years' paramedic training. I would love to say that things have changed and that we have better paramedical or even first aid skills in our emergency, particularly fire, services. In some parts of the country that is true, but mostly it is not.
Will the Minister think about the skills base of our armed forces? We learned this weekend that three of our brave Paras from the 2nd Battalion the Parachute Regiment, had died on active service in Afghanistan. However, many members of our armed forces who are injured on active service survive injuries that they would not have survived 10 or 20 years ago. Is it a consultant from accident and emergency who attends them in the field when they have been blown to smithereens or a consultant A and E surgeon who treats them when they have been shot while in the field? No. It is a paramedic: highly skilled paramedics who understand and can do the work there and then, at the incident, to keep someone alive long enough to enable the experts to get hold of them.
We have made enormous progress with the skills of paramedics and with air ambulances throughout the country, but that is sporadic, with respect to skills and qualifications. That is something that we can consider, because we need to think carefully about how money is spent in the NHS. As well as using the extra skills of the volunteers who have been mentioned—many of whom tell me, interestingly, that they have retired from the NHS and keep their hand in by using such skills—I should like to examine the skills base of our paramedics.
We have heard about the ambulance service this morning. It was a great honour for me to be asked to be a trustee of the new Herts air ambulance service—a completely charitable organisation, which was set up because Essex air ambulance was covering Hertfordshire as a charitable organisation. That is fundamentally wrong: the Essex air ambulance was in Hertfordshire, and was not giving cover to the people who had raised funds for it, so we worked together on the situation.
Alongside my hon. Friend Grant Shapps, I sat in on some of the meetings with the PCT, ambulance trust and other bodies, and I could not believe how difficult it was to agree what sort of ambulance we should have. Should it have a paramedic on board, and who would pay for that? Should it have a consultant? Should it have a trauma team? Should it be just a lift helicopter, which goes straight to the incident and, once the patient has been stabilised, is up and away to the nearest major trauma unit?
I praise the Government for initiating major trauma units. The Minister knows that I am concerned about accident and emergency and acute services being penalised, because of money going elsewhere. A and E departments are closing, not least in my constituency. However, I could not believe the lack of willingness at the meetings that I attended to say, "This is a voluntary organisation, raising money to help local people, so let us sit down and help them, rather than come up with lots of reasons why what they propose should not happen." I understand from other air ambulance trusts around the country that that is not new. The availability of ambulances is a completely ad hoc situation.
I was astonished by what the hon. Member for Winchester said about helipads. We had a short conversation about it before we came into the Chamber. To use another military example, it is possible to put a helipad down nigh on anywhere in an emergency, if necessary. Two people—one person—can lay a helipad and make sure that the windsock goes up, the helipad markers are down and there is a certain amount of space.
Frankly, it is ridiculous in the 21st century that someone who is so seriously injured that they need to be casevac'd by helicopter should be put back in an ambulance to be driven to the A and E department. I hope that the Minister will look into that and give assurances to the Chamber that, if it is taking place, it will be stopped. It cannot be what our constituents deserve. We must consider how our communities can work together better for our constituents—whether the voluntary sector, PCTs, which in some areas are under extreme financial pressure, or acute trusts, which are also under pressure financially and because they are trying to centralise services. With something so serious, Ministers must get away from saying, here in London, "This is nothing to do with us. It is a matter for PCTs and localisation."
The other day, I asked a very simple parliamentary question about which services should be available at a hospital advertising an A and E department—not a minor injury unit, a surgery centre or a polyclinic. Driving around my town, like most of my constituents, one will see signs for the hospital with "A&E" written underneath. In response, I was told that it is matter for local PCTs. That should not be the case for a question as acute as which hospital someone is taken to when critically ill. There must be a set plan for what is available throughout the country when dealing with major trauma. In my case, I took my daughter to the A and E department at my local hospital, only to be told that it could not take her, because it does not do paediatrics and has no children's facilities. Naturally, because she was very ill, it said that it would look after her as best it could and then move her to the Watford hospital.
The least that our constituents deserve is for the Government to set out centrally a basic template of what services should be available throughout England and Wales—I realise that such responsibility is devolved in Scotland—so that all of us, no matter where we live in the country, get the best possible provision that the NHS can provide.
I congratulate Mr. Oaten on raising the important question of how the NHS deals with trauma, which is an issue of interest to many hon. Members. I also welcome the valuable work of all those who work within the British Association for Immediate Care, to whom I am sure that all hon. Members present are deeply grateful. I am also sure that all hon. Members share my desire to see NHS services deal effectively with severely injured patients, and to give them the support and treatment that they need. I agree that trauma care is a serious issue on which the NHS has not performed as well as it might have done in the past.
The issue is about not only how best the NHS can deal with seriously injured patients, but who is best placed to make detailed decisions on staffing and the organisation of services. These debates often tease out the tension between the desire to devolve more powers and decision making to local and regional levels, which all political parties represented here are signed up to, and the need to explore whether there should be a stronger national framework—again, that has been well illustrated in this debate.
The Government believe that, as Mike Penning just suggested, we should give strategic direction—a national framework, if hon. Members like—to public services. However, in the end, it is for local and regional health bodies to determine the best organisational arrangements to ensure that the right people are in the right place at the right time to look after patients appropriately.
I agree that the basic infrastructure for deciding where people should be taken must be a matter for local authorities. However, the question of what type of care is available must be for central Government diktat, otherwise we will continue the postcode lottery that affects the NHS today.
The idea that the decision on what is available, and where, should be for central Government diktat is very interesting coming from the hon. Gentleman, and I might bring it up in future debates, if he is suggesting that we are being too dirigiste. However, I shall elaborate on my arguments in a moment.
The hon. Member for Winchester has rightly pointed to last year's report on trauma care from the National Confidential Enquiry into Patient Outcome and Death, which stated that every year between 3,000 and 4,000 severely injured people are admitted to hospital in the UK, so the majority of hospitals see fewer than one severely injured patient per week. The report found that hospitals that saw more patients had better outcomes, as they were more used to dealing with challenging cases. The NCEPOD report recommended the establishment of regional, specialist units and the development of protocols to ensure, for example, that ambulances take patients to the most suitable centre, bypassing others that are nearer, where it makes clinical sense. It also made recommendations on the care that should be available to patients before arrival at hospital. When it was published, the Government welcomed that report, and we will take forward its recommendations.
The NHS is already improving services provided by ambulance staff at the scene of such incidents and accidents. As the hon. Member for Hemel Hempstead has rightly pointed out, there is an interesting contrast between the improved performance of the military medical services, in the field abroad, where we have seen dramatic improvements in survival and recovery rates among armed service personnel after severe injury, which has not been replicated in civilian trauma treatment. We are very keen to learn the lessons from that. He was also absolutely right to stress the important role of paramedics, who, I am informed, already do a lot of work in unblocking windpipes, for example, which I think that he acknowledged. There could be an issue about the delivery of anaesthetics, which might require doctors being called in from elsewhere. However, we are certainly keen to learn as much as we can from the experience of the armed services, and I have already asked my officials to look into that.
Absolutely. However, it is also important, when we talk about the respective experiences of the armed forces and the civilian health service—this touches on a point that the hon. Gentleman has raised about rules and regulations for the use of helicopters—to acknowledge that different health and safety parameters can apply to armed forces and civilian services.
The Army point is interesting. I am not an expert, but my understanding is that NHS consultants who work in accident and emergency departments often work in Afghanistan or Iraq. Perhaps one of the reasons for the improvements relates to the lesson about BASICS. It may be not the trained paramedics, but the consultants working in the field who are making the difference.
We are drifting away from the subject of the debate into another important area. We are acutely aware of the benefits of the cross-fertilisation of experience between the NHS and the military health services. In fact, the Government recently published a paper asking all trusts to encourage their staff to join the TA and to gain experience in the field. The hon. Gentleman is right—the more experience that staff can gain, the better.
The other very important development under way is the next-stage review, under the auspices of my noble Friend, Lord Darzi, who published his report on the future of health services in London about a year ago. I am sure that hon. Members who are acquainted with that report will acknowledge that it recommended the acceleration of improvements for a range of care, including trauma care. The Government support that proposal and expect the London PCTs to agree their forward programme on it tomorrow.
As part of Lord Darzi's national next-stage review, we have been holding working groups of local clinicians and others in all England's other strategic health authorities to consider clinical evidence across all areas of health care, including trauma. Those groups have identified what they believe to be the best models of trauma care for patients. Each SHA has now published its vision for the future of health care in its region, based on the recommendations of those working groups. Those visions include improvements to services for seriously injured patients, for example, through the development of specialised centres for the treatment of major trauma to improve outcomes for patients and save lives.
I was interested to read the response, which inspired this debate, from BASICS to last year's NCEPOD report. It states:
"The public, patients, politicians, managers and the professions need to understand that better outcomes in major trauma are more likely in units staffed by personnel undertaking sufficient throughput and with all relevant specialties to hand. Of necessity this mandates greater regionalisation of services and patients travelling that little bit further to hospital."
I suggest that that presents a challenge to all politicians who regularly come under pressure from political campaigns to fight to preserve every service that is provided in every local general hospital. It is quite clear from the evidence, which has been widely acknowledged in the debate, that a move to more regional trauma centres will save lives. I hope that when we have such controversies in future, the hon. Members who have spoken today will support their local and regional health bodies and the Government, when we make such a case.
I am happy to set an example and say that I am comfortable with making the case to my constituents in Winchester that some things should happen not at Winchester hospital but in Southampton. If I had an accident, I would much rather go to Southampton. Surely the point is that if I am going to a specialist centre, I want to get there quickly. I am all for specialist centres, but only if people can get there quickly.
I hope that hon. Members who are facing re-election at the next election are prepared to display similar courage when it comes to the reorganisation of health services in their local area. [Interruption.]
I want to update the hon. Member for Winchester and other hon. Members present, most of whom represent constituencies in the South Central strategic health authority area, about the most recent developments there. The SHA informs me that trauma cases in its area are handled by nine acute trusts that have a major A and E department and are classified as receiving hospitals in the event of a major incident. Casualties are triaged and assessed on the scene before being taken to the most appropriate hospital to treat their injuries according to the clinical judgment of paramedics and, if needed, BASICS doctors. They are taken either by ambulance or by air ambulance. If required, BASICS volunteers are activated by the ambulance service for the treatment of casualties on scene, and acute trusts have the ability to activate their own doctors and nurses to form a mobile medical team to assist with the provision of pre-hospital care.
I turn to the hon. Gentleman's point, which has been repeated in the media, about a consultant in A and E who was a volunteer being told that they could not go to the scene of an incident. I do not know whether that example is hypothetical or real, but it has been raised before. The national clinical director for emergency access, Sir George Alberti, of whom many hon. Members may have heard, is looking into whether there may be merit in the Department's appointing a specialist trauma tsar to help to drive the national network. The danger is that if we appoint too many tsars, we will reduce their value.
Sir George was asked about that particular case recently on Radio 4. He said that that would not be acceptable, and that clinical priorities should always come first. He said that if someone was making an allegation based on a real example, they should provide him with details and he would look into it, but he has not heard anything more. If the hon. Gentleman would like to, he can furnish either me or Sir George with such an example. We have made it quite clear, as should hospitals, that if there is a clinical need for somebody to go out to the scene of an accident, that should happen—South Central SHA has told me that. Such a person should not be held back in A and E because they are on duty there or because of the desire to hit a target. I wished to put that on record for the hon. Gentleman.
The hon. Gentleman asked whether I have received a request to meet NCEPOD. I have not received such a request, but I have asked to meet NCEPOD about a different matter that came up in the past two weeks, so I am sure that we shall take the opportunity of discussing this matter. As he has acknowledged, NCEPOD has regular meetings with my officials, and its input has been important in helping us to draw up the proposals that we shall publish shortly when Ara Darzi publishes his full next-stage review.
South Central SHA informs me that it is working with the South Central ambulance service to improve the current arrangements for pre-hospital medical teams, by implementing processes to activate mobile emergency response incident teams. That will improve the performance of the trauma system, based on previous major incidents in its region and nationally. It has made it clear in its next-stage review vision document that it wants to improve care for trauma patients. The document states:
"Emergency and urgent care will be provided through a network of A&E departments" including
"specialist emergency centres for stroke, heart attacks and trauma."
On major trauma specifically, its acute care clinical pathway group report recommends that major trauma networks be established, with dedicated major trauma centres and bypass protocols for ambulance services.
That brings me to the issue of the hon. Gentleman's helipad—well, not his helipad but the one in Southampton. Forgive me, but I am not completely au fait with the likely configuration of any major trauma centre in his region. I suspect that one or two hospitals—or maybe more—are competing for that status. Clearly, his point about access to air ambulances is important, even if it is not necessarily a showstopper. I shall say a little more about air ambulances in a moment.
The hon. Gentleman has said that the chief executive of his local hospital has stated that there is a funding problem. However, I have been informed that Southampton University Hospitals NHS Trust is looking at a £17 million- plus surplus this year. The hon. Member for Hemel Hempstead has questioned the projected costs described by the hon. Member for Winchester, which may be worth consideration. If the hon. Member for Winchester is suggesting that the hospital does not have any money, that is just not the case.
We must be careful in talking about a £17 million surplus, because Southampton hospital is also paying off rather a large loan. One should not be mentioned without the context of the other, and that amount of spare money is not floating around the system in Southampton.
All that I wanted to do was put on record the fact that Southampton hospital is not in deficit. In fact, it is looking forward to what sounds to me like a healthy surplus this year, and how it decides to spend its surplus is entirely its decision.
I wish to say a little about the funding of air ambulances. We had a lengthy debate on the matter in this Chamber back in February, I think, and I do not intend to cover the same ground in great detail—hon. Members who were not present may like to study the Hansard of the debate. In the past, we have undertaken independent research on the cost-benefit of giving more state funding to air ambulances. Before 2002, there was no statutory requirement on, or guidance about, state funding for air ambulances, all of which were wholly funded by voluntary contributions. That has changed, and since 2002 we have issued guidance that the medical staff provided on air ambulances should generally be funded from public money, and that they need to work closely with their local ambulance trusts. My latest information is that that happens in almost all parts of the country, if not all.
There is another point that we might want to discuss outside the debate or in correspondence. I notice from the correspondence that I have received, from parliamentary questions tabled by the hon. Members for Winchester and for Romsey (Sandra Gidley) and from an early day motion tabled by the hon. Member for Winchester, that there is some confusion about a difference between London and the rest of the country, and I shall try to get more details about exactly what that difference might be. The hon. Gentleman has suggested that there is statutory funding in London for the air ambulance, in the way that I have just described, but that is so in most other parts of the country as well, thanks to the change in the policy that we introduced in 2002.
In February's debate, I made the point that we constantly review the policy. I mentioned that one of the problems in justifying full public funding for air ambulances is that they do not all have a good record at targeting the right sort of cases. I also said that moving to greater regionalisation of trauma care, with fewer major trauma centres, might tip the balance of cost-benefit in favour of more statutory funding for air ambulances. In that debate, I promised to keep this matter under review. I repeat that undertaking today.
I have forgotten for the moment the other issue that I wanted to mention, so I invite hon. Members to intervene.
Just to clarify the Government's position, is the Minister saying that it is not acceptable that critical pre-hospital care should be dependent on volunteers?
Critical pre-hospital care is not dependent on volunteers, because any ambulance service or acute service will have a range of reactions to a major incident in its area. I have already described the response provided by the ambulance service, which involves having ever-greater skills on board to provide some of the care. Where necessary, teams of doctors will and should be called out to attend an incident to provide such care.
I have also acknowledged that we still have some way to go in providing optimal care, that, generally, the treatment of major trauma has not advanced as quickly as advances in many other forms of care and that we have not performed as well as some other countries. This is partly to do with the different systems in other countries. The hon. Member for Winchester has made comparisons with Germany and the United States, which have different health structures, more specialist centres, different systems and approaches and far higher funding per head of population on health care than in this country.
The Minister is being generous in giving way. Can I clarify what he said a few moments ago? Should medical staff on an air ambulance be funded by the PCT or the trust under the NHS? Are the pilot and navigator, or whatever, the charity's responsibility, and should the personnel dealing with the medical skills side be funded by the NHS?
I cannot remember whether the hon. Member for Hemel Hempstead attended the February debate—perhaps one of his colleagues was here. This is not a requirement, and we published guidance on the point in 2002. Our information is that in the majority of cases those medical costs are met from statutory funding, which was previously not the case.
I should like to add one more thing about the role of ambulance trusts and their relationship with BASICS. We looked at that matter in a little bit of detail once we knew that this debate had been scheduled. We understand, having spoken to ambulance trusts, that they have clear systems that allow them and their control staff to call on the expertise of BASICS doctors when an incident demands it. As I have said, I hope that the work that is emerging from all the strategic health authorities in the context of Ara Darzi's visions will help us to improve the way in which we deal with trauma and all the health care pathways that hon. Members care about.
I am grateful to the Minister for giving way. I hear what he has said on the evidence in respect of how things are working. However, what about this statistic? There were 1,200 requests for individuals to come out, but not all those requests were meet. The evidence shows that individuals were not able to go out on 450 occasions last year. Surely, the Minister acknowledges that there is a gap and that something is wrong.
I will study those figures, which I have not seen and do not recognise. I have already acknowledged that we can do more to improve the service provided to people who are involved in trauma before they are admitted to hospital. I promise to write to the hon. Gentleman in response to the particular figures that he has mentioned, but I hope that he acknowledges that, given what I have said, the Government are determined to improve the quality of care for severely injured patients.
I welcome the consensus in this debate that the most effective way to provide the service is through good regional planning and by regional managers and hospital managers working closely with expert clinicians and the local population. I look forward to the recommendations from my noble Friend Lord Darzi's review and to their successful delivery across the country.