Tuesday, 7 May 2013

Economy of Blood: Are Private Ambulance Organisations the Problem or the Solution?

Rod of Asclepius = Healing and Medicine     Caduceus (Hermes) = Commerce

Over the weekend I was challenged on the Broken Paramedic Facebook page by some individuals who had taken umbrage at my stance on private ambulance firms.

One commenter expressed relief that my views hadn't been given the opportunity to be aired on BBC 5 Live Investigates as planned. He claimed that concerns I had raised regarding the capabilities and standards of private ambulance crews (as encountered and reported by active members of the NHS ambulance community) were “rubbish”. I have heard many genuine accounts from reliable and respectable sources of some very worrying practices concerning private ambulance organisations—some as recently as the last week—so I know the fears about private services are far from “rubbish”.

However, the ensuing debate gave me pause. Here was a fellow paramedic who felt the need to call me out on my views and defend not just his, but all private ambulance operators. This seemed like an odd decision on his part, given that he cannot possibly have intimate knowledge of the working practices of every other private ambulance organisation as well as his own. He was also (understandably) critical of NHS ambulance services. I can only assume he had not read any other articles on this blog, or he would have realised I am in complete agreement.

But I want to make one thing very clear:

Anyone who has chosen to pursue a career providing healthcare to patients has nothing to be ashamed of, no matter what pathway they use to deliver that care. Individuals with the desire to help others deserve respect, no matter what uniform they wear or what their level of clinical skill is.

State of Emergency

The present pre-hospital healthcare environment is far from ideal. Collectively, the appropriate level of clinical care is not getting to the right patients in the right time-frame. Undoubtedly, the failings of NHS organisations—and ultimately the Department of Health—are key to this. This is not something that rank-and-file practitioners from any discipline are responsible for.

Poor management decisions and failure to provide sufficient resources has left the publicly funded ambulance organisations unable to deliver the service expected of them. Meanwhile, private organisations have capitalised on this, feeding on the chaos and claiming a moral high ground they have no right to.

As a result, pressure on NHS front-line staff has increased: they are expected to do more and more with less and less. Working conditions have deteriorated and experienced personnel are increasingly looking for a way out of this soul-crushing treadmill. Good men and women continue to bleed over to the private sector, further weakening front-line NHS forces. Years of experience are lost as valued staff are driven away by mismanagement or injury. Many of them migrate over to private firms who can offer better rates of pay and more reasonable working conditions.

Who can blame them?

But they are pawns in the rich man's game.

It is my perception that, as the NHS-provided services continue to be wilfully eroded by under-funding and mismanagement, private firms wait in the wings, hungry for the business. In both sectors, the clinicians on the front line are likely cut from the exact same cloth, but the motives behind the organisations supporting them are very different.

Unhealthy Competition

For all its modern-day failings, the NHS is built on the laudable principles of providing healthcare to those who need it rather than those who can afford it. Fundamentally, this is what medical care and first aid has always been about and should never need to change. If you need a reminder of the history of this vocation, go read The Charge of the Ambulance Brigade elsewhere on this blog. You really should, this article can wait.

All things being equal – imagine, for simplicity's sake that both private and publicly-funded ambulance organisations start with equal staffing, skill-sets and resources – then the defining difference is that, whilst the public organisation can use all of its resources to further its ability to better deliver its services, the private organisation needs make a profit to justify its existence. This means that in order to create a profit margin, they will either be the more expensive option, or they must reduce costs by relying on lower-skilled staff or less equipment, thereby comprising clinical effectiveness. They might then be tempted to obfuscate these facts in order to remain competitive. Quite clearly, the private sector solution is the less attractive option than the publicly-funded, more cost-effective, more honest organisation.

This is without taking into account the phenomenal buying power of the NHS, who can buy in such bulk that they can command a much better price for consumables and equipment than competing private firms can ever hope to.

Of course, this is an imaginary ideal in which both types of organisations are managed efficiently and logically. In reality, we have seen that this has been far from the case. Instead, what we are seeing is a scenario where NHS ambulance services have been throttled into ineffectiveness by the government. This has been compounded by inexplicable management decisions. Yet, even with the most effective management and resource use, they were—and remain—destined to fail.

Private sector ambulance services seem to have become the only viable solution. They have the manpower and the resources on standby, ready to save the day. These resources will be a blessed relief when they are effectively utilised to bail out their struggling public sector comrades. But these are resources that have been built up by steadily siphoning money out of NHS coffers. The aforementioned “inexplicable decisions” have often been to the benefit of private enterprise. There is evidence readily available that millions of pounds of NHS funds have been inappropriately spent on private contracts, money which could have been better used to bolster NHS resources rather than allow private firms to build up their 'rescue package' capability.

To me, this seems like saving someone from a mugging by tearing the victim's own arm off to use as a weapon to fight off the attackers (and then expecting a reward).

Standing Together, Maintaining Principles

I have no doubt that the front-line clinicians who work for private ambulance firms mean well, but surely they must be aware that they are being manipulated to work against a far more philanthropic cause that underpins the best of what their chosen vocation represents.

Why support private organisations which aim to make a profit from the ill health of others, when there is a viable, ethical, publicly-funded alternative which could and should be the better option?

You will get no argument from me that public sector ambulance services have been poorly managed, but this does not have to remain the case. Certainly the NHS doesn't have a monopoly on ineffective leadership - privately-led companies have the capacity to be just as incompetent (banking springs to mind), but also have the temptation to be malevolent, with the added need to look for the most profitable type of work at the expense of the patient. Should the legitimate healthcare professional really be supporting that kind of working practice in the healthcare environment?

If respectable clinicians who set out to help those in need are now single-mindedly chasing the dollar, then the cause is already lost. We may as well shut down what’s left of the NHS, let the poorest and hardest to treat die, and just provide a service for those who remain. It will be far more cost-effective and a much more sustainable business model. It'll certainly take a lot of the pressure off of front-line medical services, improve working conditions and cause a boom in the funeral trade.

Fortunately, I don't believe this is a future that any right-minded individual wants. I think the altruistic drive instinctive to every healthcare professional is being subverted by those with far more selfish agendas. Every medical clinician in the land has a duty of care to stand in the way of this opportunistic tide of mercenary healthcare.

Watching or supporting ultra-capitalist forces slowly throttle the life out of the NHS is not an option.

Do not let the government float the economy on blood.

[*The title image shows the Rod of Asclepius, an ancient Greek symbol used to represent healing and medicine often found in modern ambulance livery and the ironically similar Cadaceus, or Staff of Hermes, the Greek god of Commerce and guide to the underworld.]

Sunday, 5 May 2013

Is the EEAS Turnaround Plan Just a Fantasy?

Earlier today, BBC Radio Five Live covered the ongoing crisis at East of England Ambulance Service. The programme is well worth a listen whilst it is available on BBC iPlayer, with accounts from an anonymous whistle-blowing paramedic (my hat is off to this gentleman for his very professional and earnest delivery), the bereaved mother of a baby who died allegedly as the result of ambulance delays, and an interview with EEAS chief executive Andrew Morgan.

I had been scheduled to appear on the show but was dropped at the last minute (I had spoken briefly on 5 live’s Weekend Breakfast at 0640 - 41m 45s in). I was deeply disappointed by my eleventh hour exclusion - this felt like an opportunity missed to offer an honest and informed overview as well as the chance to discuss how the general public and the government need to take some responsibility rather than just scapegoating the ambulance services whilst absolving themselves.

A Brighter Future?

However, the silver lining was that my preparations did give me cause to read through the recently released East of England “turnaround plan”. Mr. Morgan 's document, entitled 'Delivering better services for our patients' made for a thought-provoking and inspirational read.

I can honestly say that my first read of the document gave me a sense of vindication and of hope.

Vindication because there is a refreshing candour to the opening segments, in which many of the problems which I have written about previously on this blog are identified; lack of resources, untenable working conditions, misdirected priorities, leadership which is either delusional, arrogant or absent and many other sins are all laid bare.
“We are not delivering our 999 service, which is our core business, well enough.”
“We need to provide more front line resources, particularly double staffed ambulances...”
“An insufficient focus on the health of the organisation, in pursuit of performance response targets.”
I felt hope because, if all these sins are addressed and if Mr. Morgan's vision of EEAS's future can be realised, then I will be living in a part of the country in which I can have confidence in the emergency pre-hospital healthcare services.

A confidence which is currently not deserved.

Over the Top?

Andrew Morgan's concluding statement is so inspiring and aspirational it almost makes me sad that I no longer work for EEAS (rather than the usual emotion of thankful relief). He wrote;
“We need to make progress on all areas of this turnaround plan in order to recover the health of the organisation and deliver sustainable performance and high quality services for our patients. We know we work in changed times, we know that this is having an impact on the lives of our staff and we know that we are failing some of our patients. We have to change. We have to demonstrate better leadership. We have to support Staff better. We have to provide more resources for front line service delivery. We have to deliver good clinical outcomes for our patients. We have to ensure we make better decisions about how we use our valuable emergency response vehicles. We have to use our clinical skills better to guide patients to access the health service in a way that will support their long term health. We believe that by doing this we can keep more people at home, when it is appropriate to do so.
We must push for investment in the service when this has been proved to be justified and we must create a service that delivers what our patients need. We must support staff to make changes locally and we must listen to patients more. 
The future of this organisation is in our hands. As a Board we know we need to do a better job at leading the organisation. We hope that staff will work with us to implement the changes that are necessary to restore our collective pride and passion in what we do.”

Powerful, stirring words indeed. The kind spoken by a leader who can perhaps rally dispirited troops and give them belief in the cause once again. Right before he sends them over the top and into the enemy guns he secretly knows they cannot defeat.

The reason I say this is because, sadly, I do not believe that Mr Morgan's well-meaning turnaround plan can possibly work. This is no reflection on him - he can only work with the tools and resources he is given, but I believe the government taskmasters to whom he answers have set him up for failure.

Not Enough Funding

The need to make £50m savings remains, yet despite stating that “the cost of implementing this turnaround plan is predominantly going to be found from within existing budgets”, Andrew Morgan somehow feels able to conjure “the equivalent of an additional 25 24/7 DSAs provided directly by the Trust.”

This will apparently be achieved by “recruiting to our vacancies, reducing staff sickness and reducing our spend on private ambulances” and “recruitment to our additional posts” but I am concerned that the funding figures don't add up.

In September last year, public outcry regarding reduced ambulance coverage in North Norfolk resulted in £3m being found which enable 2 (nearly) full-time Double-Staffed Ambulances to be reinstated. So going by that, a single full-time DSA costs just over £1.5m to staff and run for a year.

The turnaround plan states that approximately £5m can be found from elsewhere to fund this initiative, leaving only the private ambulance spend and the nebulous concept of reducing staff sickness (overtime cover costs?) as the source for the remainder of the total £37.5m (£1.5m per ambulance x 25) bill for these proposed additional vehicles. Even if the entire monthly private ambulance bill (an average of £750k) was redirected, that will still total less than £15m. As bad as staff sickness may be, I doubt the very optimistic plan to aggressively reduce this over a six month period will result in saving the remaining £20m.

My scepticism is further compounded by the fact that earlier this year Mr. Morgan promised the “additional resources” of 15 ambulances and 200 staff, which turned out to be recycled old ambulances left unused due to staff shortages, and the promised staff (which did not appear in the timescale promised) were simply replacements for existing unfilled roles. It was all empty spin.

That is not to say that Mr Morgan is attempting the same trick again and I genuinely believe that the reality check has finally reached the top. This is a broad and noble plan which promises fundamental cultural change—including repeated oblique references to addressing a senior management problem some might refer to as the 'Essex Mafia'-- as well as a significant uptick in available resources for the “core business” of 999 responses, and a greater respect for the front line staff.

The problem is, it seems too good to be true, so it probably is.

Reverse Psychology?

Perhaps Andrew Morgan's plan is prove to the Department of Health that more funding is desperately needed to avert further disaster. This could certainly be inferred from the statement;
“Any new funding requirements identified as a result of the actions in this plan, will be discussed by the Board with a view to identifying the potential sources of this funding. This may involve seeking transitional funding from elsewhere in the wider NHS.”
There will undoubtedly be “new funding requirements” if the plan is to succeed and I hope Andrew Morgan is setting the stage to make a watertight case for exactly that. I eagerly await the results of the “clinical capacity review” they have commissioned, which “will determine how much of any gap in resources can be filled by internal efficiencies and changing working practices and how much will need to be discussed with external stakeholders and commissioners.” The results are due “late May 2013”.

My greatest fear is that this plan will be attempted without the resources necessary to see it through. Without backing from the DoH and a government willing to do what is necessary to stop the rot, we will see partial implementation, leading to greater demand on dwindling staff already stretched far beyond reasonable levels. The fantasy will become a nightmare as we simply end up with another post-Bradley Report attempt to fulfil lofty ambitions using only the existing personnel, which will break them.

How many broken paramedics do you need Mr Morgan?