Wednesday, 3 October 2012

How the Public Could Save Their Doomed Ambulance Service



So far on this blog, I think we've established that the "ambulance problem" is huge. Every opinion I have heard - from the public to paramedics to chief executives - has underlined the many intolerable issues that beset patients, crews and the service as a whole. The problems are so vast and manifold, it seems as if those in charge are incapable of addressing them, choosing instead to skirt around the problem, chipping away at minor contributing issues instead of tackling the core cause head-on.

Part of the problem is the vast differences between how various key parties perceive the ambulance service. In an effort to address the "ambulance problem" constructively, far more needs to be done by these parties to agree on what the ambulance service is for and then to execute that single purpose with efficiency and professionalism.

The Public Perception

Ultimately, the ambulance service is there to serve the public. But does this mean that the public knows best? Not at all. Few members of public give any thought to the ambulance service until they find themselves in a situation they cannot deal with, without outside help. The convenience of the 999 service means that for many, it is a catch-all solution. From their perspective, dialling 999 is the instant answer to a broad range of unmanageable problems. In some respects, this is good thing. It means that the UK public have faith in the emergency services provided. But the public demand on ambulance services lies at the core of the problem and the current inability to meet it is already eroding that faith.


So why do the public have this perception of the ambulance service's ability to deal with all health problems rather than just emergencies? I would argue that it has been brought about by a number of factors, but a large contributor is because that is how the ambulance service has sold itself to the public in the recent past. It is a legacy of the Bradley Report "Taking Healthcare to the Patient" which, in 2005, set out a national template to provide "effective mobile healthcare". In the face of rising demand, Peter Bradley set the UK's ambulance services on a path to adopt a more holistic approach to the services provided.

On reflection, this seems naïvely optimistic with a touch of hubris. Essentially, the report declared that UK ambulance services were capable of taking on more work despite identifying a yearly rising demand of 6-7%. This apparently created a belief amongst the government decision-makers that the lofty healthcare goals set out by the Bradley Report could be achieved with existing resources, simply by reorganising ambulance services which, at the time, were described as working "harder rather than smarter".

Repeating the Same Mistakes

Now, seven years later, this same naïve philosophy is being touted as the solution to the current crisis. Despite a continued year-on-year increase of demand, a "fiddling whilst Rome burns" approach to re-arrangement and tweaking of resources will once again kick the can down the road whilst the results are analysed and debated in committee over the following months or years. Meanwhile, demand will continue to rise, patients will more frequently be made to wait and suffer, road staff will continue to be stretched thinner and thinner. Clearly, lessons have not been learned.

So the public perception of an increasingly unreliable service will grow. There is already no shortage of media coverage showing how seriously wrong things are. This brings us back to the core problem. The painfully mismatched juxtaposition of increasing demand and falling resources will not be resolved by half-measures like better call-handling and refining the application of existing resources. Making the service provided more efficient is of course a necessity and would be expected of any organisation, but it is glaringly obvious that current resources are not nearly enough to cope today. They are minor changes which cannot possibly make a dent.

The reason for this is because there is a on ongoing failure to address the core problem.

Public Responsibility

Vast sections of general public do not have the education, understanding or desire to work with the ambulance service to make things better. In today's consumer led environment, the ambulance service labours to provide the service that is expected of it by modern society, whilst most consumers simply expect the service they feel they deserve to be provided. In decades past, people would be grateful for a stranger to provide help. Now they pay their taxes and expect the NHS to provide everything - end of discussion.

Modern, materialistic, over-entitled, convenience culture is key to the rise in ambulance demand. 100% of the general public in the UK rightly expect a world-class ambulance service (and on occasion, they get it). But does that same 100% of the public also know what to do before an ambulance gets to them? Not even close. Sadly, the outcome of many emergencies are decided before a healthcare professional ever arrives. Even worse, so many ambulance resources are used dealing with problems that are not appropriate. Vast amounts of money are being spent attempting to deal with this misappropriation of resources, but not nearly as much in educating the public.

There are of course many individuals who do make informed decisions and use existing services responsibly, but they are a minority. The ambulance service is being slowly crushed under the weight of a self-serving public attitude - they expect the help, but will not help themselves.

Shockingly, the problem does not end with the general public. Elements of NHS culture itself cause a further strain on emergency resources. Whilst the ambulance service - a comparatively modern concept - works on the logical basis that people become ill twenty-four hours a day, seven days a week, other aspects of UK healthcare cling to the concept that reducing cover outside of core office hours is acceptable. After all, people rarely have problems at weekends or during the night, right? GP services are particularly guilty of this - begrudgingly putting on a skeleton service in "anti-social" hours - which, due to public perception, essentially shifts their workload onto emergency ambulances. Anecdotally, I found the number of 999 calls from GP surgeries close to the end of their working day suspicious too.

This same culture also causes similar workload bottlenecks within hospitals and even in the ambulance service itself - exhausted crews at the end of an intolerable shift might take a patient to hospital unnecessarily - or leave a patient at home inappropriately, in a desperate bid for some respite.

The Result of Cultural Abuse

The end result of this cultural abuse is that a service that is only funded to provide emergency care is unavoidably attempting to provide a much broader service. If the funds are not available to provide Peter Bradley's "effective mobile healthcare", then the public should be clearly informed as such.

As was pointed out in a recent message I received from a reader; "there are two ways to go about funding anything, the right way is to decide on a level of service and foot the resulting bill. The wrong way is to set a budget and keep to it and suffer any consequences which may arise from failing to meet operational targets." The latter is the current approach.

Today's ambulance services should not be forced by NHS culture and government targets to pretend they can provide services that are far beyond their capability. Equally, they cannot be held accountable for the shortcomings of a society filled with individuals not prepared to take responsibility for themselves and each other.

Ambulance boards need to stop fiddling whilst Rome burns and must take a more hard-line approach to saving the organisations they are pretending are still functioning well. They have to stop being held hostage by government budgets and targets and - more importantly - they need to stop deceiving the public and deluding themselves.

Save Yourselves

The public themselves need to step up if they wish to continue enjoying the privileges of healthcare deserving of a progressive first-world nation. The majority of adults have taken the time to learn to drive, but far fewer have been prepared to devote a similar amount of effort to learn basic first aid or even taken the time to understand their own medication. In modern life, people do not have the time or motivation for something they perceive to be trivial or inapplicable to them.

It is fair to say convincing the entire adult population of the UK to take more responsibility to learn basic skills is a gargantuan task. But children in schools are a different story. The simple inclusion of a few days first aid training and education about how the NHS works as part of the National Curriculum (perhaps in Biology or Physical Education?) would soon produce an entire generation of informed people creating a future where first aid is commonplace. Knowledge would spread, common sense would prevail and public perception of the ambulance service and the NHS would be more accurate and more affordable. The general public would be in a far better position to make informed decisions and the resultant cultural knowledge shift would have a positive impact on the society’s demands throughout the NHS.

Everyone gets ill, everyone dies. Informed or not every individual in the land will, sooner or later, find themselves in a critical situation, yet the modern consumer will continue to expect somebody else to know what to do.

Hence the public’s present solution: Just dial 999 and hope.

18 comments:

  1. By far the best I have read so far. EDUCATION EDUCATION EDUCATION!!!

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  2. North Norfolk resident4 October 2012 at 18:26

    I see in the papers that there is talk of dishing out £70 fines for every ambulance kept at A & E for longer than 15 minutes. Not sure who is hoping to hand out the fine, who is going to pay it and who is hoping to gain from it! I guess the answer is different NHS departments. So what’s the point when they are all desperately trying to cut back expenditure? This seems like yet sillier tinkering. It all needs taking by the scruff of the neck and shaking. Meanwhile I totally agree with Mat – get educating the masses of the future!

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  3. Excellent piece and on the right track for finally dealing with the problems we face. As for the EEAS and the problems of call volume and manipulation of figures and how awful it is to work in the ambo service today, we should take a bit of comfort from the old saying "you can run but you can,t hide". Over time things always tend towards the average and so these problems ,one day, be exposed for what they are. The only thing needed is time. It won,t be long before the system breaks down or more likely(in my view) there will be a tragedy where someone dies because there is nothing available to send them and the papers get hold of it and the spotlight falls on our ( highly paid) senior management. In the private sector there is a "survival of the fittest" filter that promotes quality people to high positions and they tend to make good decisions (thereby making money for the companies). In the public sector there is tendency for promotion of mediocre people to high positions and they tend to make bad decisions because that filter does not exist (the money pours in no matter what the performance) A lot of the senior people running our service are what i would call pseudo experts in that they have the talk but not the walk. To a layman or someone outside the service( such as government ministers!) they will appear knowledgeable and their arguments reasonable and their solutions to the problem will be filled with facts and figures and demand analysis etc but the solution will always be: more money please! as they do not have an understanding of the fundamental problem facing the ambulance service today: The majority of the people who get an ambulance DON,T need an ambulance! Result is tons of money, tons of waste and a poor ambulance service. All the solutions they come up with all begin AFTER people pick up the phone to dial 999 and they,re not working,because they have created a culture where nobody in the service dares stand up and makes a decision to say no to people through fear of making a mistake and losing their jobs. Stop people calling ( by education, publicity, fines, rewards etc) and we will be on the way to making the service better and our lives easier.

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  4. We have been throwing money at chasing time based targets for too long, with not enough emphasis on why the public feels the ambulance service is the answer to all their problems.

    The ambulance service is the overflow of the overly expensive GP service and other community based health and social services and now these are being cut the demand will rise further for 999. Money should be put into educating the public, starting with the next generation, that YOUR health is YOUR OWN responsibility first and foremost.

    How many ambulance staff do you see standing outside stations or hospitals smoking? From my experience ambulance staff have to take on a share of the responsibility towards educating the public. I work with some fantastic intelligent people but too many times some just turn up and get the punters in the back of the truck and trundle off to A&E. That doesn't stop them calling 999 for the single episode of vomiting or the 2 days history of cold symptoms. Although the alternative care pathways are now being cut they were often under used by some staff to bone idle to consider the option or to talk to the patient and explain the correct treatment they should follow. I've even known crews giving frequent callers gifts and souvenirs.

    I might not agree totally with the cutbacks and yes the workload is at breaking point and our T&Cs are under attack but if we just keep laying the taxi service on a plate then the public will keep on gorging themselves on it. Maybe if it is a rarer commodity then it might get treated with greater respect?

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    1. It is more often than not, those not ' bone idle' that considered and indeed used the alternative care pathways that find themselves involved in disciplinary procedures with the hpc. Can you really blame people for taking the easy option ?. Charging for inappropriate calls,whether by gp's, hospitals or Joe public would be my solution. Fees apply to many other NHS services e.g.dentists or prescriptions so why not ?. It worked for the fire service.

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    2. You don't get sacked for taking a patient to hospital...

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    3. nope. you just keep adding to the problem.

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  5. A pay up or bail out ambulance services agreement may be a way forward?

    Leaflets are distributed to all patients via their surgery, to alert ALL patients of the changes to the ambulance service. An advert on TV will also alert ALL to the coming changes. If possible the surgery/DHSS could have already requested a consent form ALL to their understanding of such changes. All residential patients are required to have the below information to hand for the ambulance crew or a delay may occur in the locating of such. Or perhaps a personalised number can be given to ALL.

    Changes below...


    Once the 999 call has been connected (and logged) through to the ambulance service, a recorded message of; "if the ambulance service was deemed unnecessary a charge of their services will occur" press one to continue. The same recorded message to be played on ALL NHS Direct calls too. Not only will the caller of the patient have to provide location, name, nature of call to the best of their knowledge. They will also have to provide National Insurance number if possible, number plate details if car accident. If the injured person has lack of any details or is in no state to provide such -a photograph will be taken on arrival at the hospital once they have stabilised the patient. The patient is assessed by ambulance crew on their journey there, also on the hospital grounds as to whether an ambulance was necessary for each individual case. If it was deemed unnecessary for the patient to have requested an ambulance a £120 fee to cover costs will be issued. To be paid within two weeks, by patient or a family member. A website/news page to will be created to name and shame those photographed who did not pay the fee, court hearing if possible. Those who did not pay will be placed on a database complete with photograph, and a refusal of any further ambulances will occur. This was stated clearly when they signed the consent form at the doctors/DHSS. Deductions will be paid in full via DHSS.

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  6. Ah, I see it is too late to make a few amendments on the above - ho hum!

    Thank you for sharing this article.

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  7. Education won't make a difference to the calls; if people need/want to call, they will - and do. Charging is an emotive response, but one which I don't feel would be helpful. Perhaps then, logically, that leaves each service in a position to start taking more effective control over who, and what they send resources to. But of course, that isn't happening any time soon...

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  8. Anonymous 16th October 2012 18:20.

    Is that a reply to my comment of 11th October 2012 14:10? If so, see my reply below.

    If John and Jane Doe were made aware there is a risk of being charged/fined for wasting vulnerable services, they will, in due course, seek alternative transportation arrangements to the hospital. The likes of a simple nose bleed/sore throat will be of another era. Once an example has been set via the courts I am sure Joe/Jane will pause before they make a 999 call.

    You mentioned the monitoring of calls to be more effective. I have read so many stories of elderly patients waiting four hours for an ambulance to arrive. So I think it is fair to say this IS already happening, however, proved to be of dire consequences.

    As the river flows downwards, it widens - just like our nation...

    http://www.telegraph.co.uk/health/healthnews/9587979/Fire-service-called-in-50-times-to-winch-fat-people-out.html

    There needs to be a dramatic change.





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  9. It wasn't a reply to your post. You slightly misquoted me as well. I didn't say monitioring calls was more effective, I said more effective control needs to be taken on the resources there are, and where they are sent. In other words, invoke a more robust, "No Send Policy."
    Granted, many elderly people are scandalously left for hours when they fall. But what isn't mentioned are the number of resources sent to the seemingly more serious calls instead, which are anything but (usually due to a wonderful piece of software that apparantly knows all).
    Whilst I don't wholly agree with, or see a complete solution in your suggestion, I admire your optimism.

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    1. Anonymous 18th October 2012 17:35.

      Apologies if you feel I have misquoted you, it was not my intention. Perhaps I have read your comment slightly out of context. I will presume you meant a more effective control over where and who the resources are sent to - as opposed to what is currently the status? I know the calls are assessed, but to what degree is unbeknown to myself. Do correct me if I am wrong.

      I agree with your "No Send Policy" but, what of those who do not understand English? Now we enter another dimension. What if, a claim for negligence was to be filed against the ambulance service for having not received one? Back to the consent form, that ALL agreed upon prior any enlisting with a local GP,work, DHSS or otherwise. To be signed at birth by the parent/carer. To ensure the consent form was fully understood the consent form would be available in various languages.

      My mentioning of the elderly lady who waited four hours for an ambulance had indeed broke her hip was a neighbour of mine. The daughter who was present with her mother at the time, was asked if her mother was comfortable. The daughter agreed that she had dutifully made her mother comfortable on the bathroom floor. I know the ambulance service are of no fault with this particular situation. Clearly, there is a need for change. You have an advantage over myself of knowing how the system works. No doubt, Joe/Jane are fully aware of such key phrases, buzz words and the likes, of which equal immediate action from the ambulance service, hmm!

      Yes, an enforceable contract for those who do not comply. Yes, it is an emotive response, but, I feel it is a necessary evil.

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    2. "What if, a claim for negligence was to be filed against the ambulance service for having not received one?"

      There-in lies the answer. This is precisely why the one thing that would make a big difference, will never happen. The what-if. Unfortunately, this also means that resources are sent where they are not immediately needed, and many people who should receive a quicker response, don't get one. This also touches on the "key-words of activation" point you correctly mention, which is partly to blame.

      I cannot understand why if most calls received by control-rooms are not life-threatening, why we are judged so stringently on them, and send such quick responses to them. Only approx 1 in 10 of all "RED" calls end in a hospital pre-alert. Surely this is worthy of note. By not doing the one, we over-triage instead, which causes more problems than it solves.
      This is a difficult one to reconcile, but its already happening - only in reverse - so if the benefit of doing this FAR outweighs the calculable risk...

      It's not an easy puzzle to solve, but currently the powers that be seem unable to even locate the pieces from it.

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    3. Of course it is worthy of note, Anonymous. Indeed it is a valid point.

      I am glad you gave me a percentage upon the average RED calls, as this gave me a greater understanding.

      I have been researching other UK emergency vehicles. It is beyond me why a more cost effective alternative is not being sent to the non-emergency calls. Such as, the medical response motorcycle was extensively used for Medical Incident Officer duties during the 2005 Portsmouth International Fleet Review and International Festival of the Sea. The Honda BASICS emergency doctor's motorbike was noted to have been sort-lived, why? To me, is seems the perfect solution to those non-emergency situations. Whereby the patient can then be told in person by a professional that an ambulance is not necessary.

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  10. True story.

    I was in my local pharmacy a few months ago. When two woman aged about 70 shuffled in. One shouted over to the other "look Betty, it's FREE, can you reach one of those for me" as she pointed to a box near the counter. The words on the box FREE were so large, that was all she was able to read. Betty hobbled over to investigate what was on offer for the day, she turned to the other and said "oh Edith, I don't think you will be needing one of them, it's a FREE chlamydia test." Edith and Betty roared with laughter, as did a few others who were waiting in line to be served - hilarious moment!

    The moral of the story is, because it was FREE and they were entitled to it they were going to take one, whether they needed it or not, you see!

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    1. Silver surfer Norfolk20 October 2012 at 23:56

      I know this is a really serious and frightening blog, but thank you for the brief smile in this terrible horror story! I'm sure the old ladies would probably have taken 2 - just in case!

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    2. Hello Silver Surfer ~ I am pleased I raised a smile, albeit momentarily :)

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