Wednesday, 27 July 2016

Who Cares for the Carers?

Last week, I was invited to speak at the NHS Pathways National Partnership Forum, a gathering of 111 providers, clinical commissioning group representatives, technicians and policy-makers who are focused on improving the telephone assessment service. I took the opportunity to offer some insight into the 'view from the trenches' in support of encouraging an evolution of the system toward a more positive and effective working relationship between 111 providers and ambulance services.

This is the transcript of my presentation (along with some of the slides).

Good morning, my name is Mathew and I work as paramedic clinical advisor at Herts Urgent Care - 111 providers for Hertfordshire, Cambridgeshire and Peterborough. 

The reason I've been invited to speak today is because earlier this year I made some impact in the mainstream media in an attempt to address some widely perceived misconceptions about the 111 service. It is my hope that I might also be able to provide you with some insight into the complex relationship between Pathways-trained clinicians and our frontline brethren.

So I'd like to take this opportunity to share with you some of my thoughts and experiences relating to that, from my perspective as a 111 operative, a former frontline ambulance clinician and in particular as an active user of social media.

You see, I'm in a fairly unique position as a result of a few unexpected twists and turns in my paramedic career. If you'll indulge me, I'd like to give you a little background.

After more than a decade as an emergency ambulance clinician, I retired from frontline service in 2012 due to a spinal problem which - at the time - left me with some mobility problems and quite significant pain. As I recovered slowly at home, the time gave me the opportunity to start a blog, the Broken Paramedic, which enabled me to address and discuss concerns and issues that affected the ambulance sector.

Well, I say I 'took the opportunity', in truth, it was my Mother who convinced me to redirect my blogging experience to challenge growing fears about ambulance cover in her locality of North Norfolk, which had already been suffering from a poor level of service and was facing a further reduction in ambulance cover. Ultimately, common sense prevailed and the level of ambulance cover was actually increased.

I was surprised by the impact of my first few blogposts and I soon found myself being invited to write an 'expert opinion' column in the Daily Mail's campaign against A&E closures. 

Since then, the Broken Paramedic online presence has grown organically into something of a loose community comprising allied healthcare professionals and interested members of public, which continues to cast a critical eye on many aspects of the ambulance sector - and associated primary care interests, often quite ferociously. Contributors certainly don't always agree.

I've been able to challenge some of the more dogmatic aspects of ambulance culture, and to give a voice to those who might previously have been silent. For me, one question keeps popping up: who cares for the carers? 

It has also given me the opportunity to work with various other media outlets and documentary teams, including a number of radio appearances and even a brief visit to the red sofa of the BBC Breakfast studio.

It was in August last year that, for various reasons, I applied for the role of 111 clinical advisor in my home county of Hertfordshire.

I think it's safe for me to say now that - as well as being curious - I was, like many of my frontline colleagues, a little suspicious. My time out on the road at East of England Ambulance Service had left me with a disdain for anything that I perceived to be causing unnecessary pressure on increasingly beleaguered ambulance staff. In my time, this was an accusation often leveled at NHS Direct, our own dispatch, the ambulance management, the Trust board, the government, the public. Sometimes it was justified. Sometimes it wasn't. But in any case, it was no surprise to me that contemporary staff were pointing the finger at 111. 

The experience of working in emergency pre-hospital care shapes you. In many ways this is a good thing, helping to develop clinical knowledge and the soft skills that working in such a varied and challenging environment requires. But in other ways it causes damage. For most normal humans, it's just not possible to sustain a consistent levels of empathy, clarity and tolerance for 13, 14, 15 hours of consecutive emergency calls.

So I approached my new role with some trepidation, acutely aware of the fact that I was signing up to be the primary scapegoat for my former colleagues and my readership.

As I grappled with the concepts of telephone triage and using the Pathways tool to support my clinical assessment I started to see the similarities between and the differences from my former frontline role. 

The differences were obvious; I now do a lot more sitting down (which is great for a dodgy back), and I encounter far fewer traumatic sights and strange smells (notwithstanding the occasional peculiar lunch choice from the next cubicle). I've not once had to find a change of clothing halfway through a shift. The hours are a lot more predictable too.

But there are similarities. The emotional reward of spending some time helping somebody who is struggling to cope in some way is something I had missed during my retirement. But now as a clinical advisor I get this dopamine hit far more frequently than when I was on the road - my rate of positive interactions can now be upwards of 5 an hour rather than a few times a shift.

The oddest similarity, and perhaps given the focus of this forum, most relevantly, is that Pathways is essentially my new crewmate.

Ask any ambulance roadstaff and they'll tell you that your crewmate is of critical importance to your working life. How you work together to get the job done defines what the patient, your crewmate and your own self takes away from the experience. There are ideal crewmates and there are those that are... less than ideal. I've had both. I've been both.

It's that buddy-buddy relationship that has been the focus of so many Hollywood movies and I think the chapters of every ambulance clinician's career are defined by the crewmate they had. Of course, I went on to marry one of my crewmates, so perhaps I'm biased.

In any case, Pathways has big shoes to fill. (I'm not saying that my wife's got big feet or anything, you know what I mean).

This is the professional relationship that empowers your clinical decisions, that keeps you on track when your focus drifts, that comes up with that genius insight that hadn't occurred to you. This is what Pathways is excellent at.

Of course it's also the working relationship that provides moral support when things aren't going well, takes over if you and the patient aren't quite connecting, and knows how you like your coffee. Pathways is absolutely terrible at that. 

Over the last year, my relationship with Pathways has evolved, and it's been an education. It's often been the reliable, no nonsense Sherlock to my empathic but meandering Watson. It's grown from a slightly jarring, forced interaction into a productive, effective relationship, despite Pathways' tendency to railroad the conversation and interject with ridiculous requests ('no Pathways, I'm pretty sure this elderly, bed-bound dementia patient hasn't been to West Africa in the last month').

I soon came to realise the importance of the work we do at 111 and the impact it has on primary care, particularly the emergency ambulance sector. I realised that some of my more frustrated frontline counterparts were getting things wrong.

They're not wrong to be frustrated with their lot - I know how it feels to be stretched thin, used and abused and squeezed to the point of broken exhaustion on a regular basis. They're not wrong to identify when a 111-generated emergency ambulance response turns out to have been inappropriate to the patient's needs. They're certainly not wrong to identify that there is room for improvement – of course, there is.

But I believe the are missing the mark to lay the blame on 111 staff or the service as a concept. My experience of a functioning 111 call centre has been diametrically opposed to the horror stories the likes of the Daily Mail has portrayed in recent months. Day in and day out I see good people working hard to provide an informative, empathetic and professional service which the demand clearly shows that the public wants and needs.

Which is why I felt it was important to leverage the social media platform I had built to challenge the misinformation peddled by some mainstream media outlets and to address the concerns of my ambulance brethren.

With Herts Urgent Care's endorsement, I was able to use my media contacts to provide an alternative view in The Metro, which was well received and widely read to the point that I was approached by ITV News to provide a counterpoint to their prime-time story on concerns being raised about the safety of the 111 service. It is my belief that much of the concern arises from a broad misunderstanding of the service provided and the limitations, both among the general public and, it turns out, some healthcare professionals.

Following on from that used my Broken Paramedic blog to tackle some myths and misconceptions that persist among ambulance staff.

This was generally met with a conciliatory tones of understanding and agreement from my ambulance readership, although some concerns raised are valid and worthy of further consideration – particularly with regard to the information which is or isn't passed from Pathways to ambulance dispatch to attending crew. And of course there are always a few who are just too angry to hold a conversation with. 

But I didn't come here just to say how great I think 111 is - there are some uncomfortable truths that need to be faced by 111 providers, ambulance trusts and the general public. Absolute safety cannot be guaranteed nor should it be promised. Healthcare just doesn't work that way.

But I don't think we should be shy about showing how safe and effective 111 currently is, nor should we back away from discussing how it can be improved.

The growing call demand that 111 and 999 services are experiencing is evidence of the public's faith in both. However we need to foster greater faith in each other.

Some of my most rewarding work is when I successfully identify cases Pathways wanted to send an ambulance to which can be safely downgraded. Some of the most frustrating moments are when I have no choice but to send an ambulance on safety grounds, knowing that in all likelihood the attending crew will be silently cursing my name for wasting their time and unnecessarily adding to their exhaustion.

It would be of great benefit for both of these kinds of cases to be part of a better communication between 111 providers and ambulance services, but not at the committee level – at the grassroots level. If my clinical assessment could land on the screens of the attending ambulance crew to explain the reason for their attendance, I think a lot of hearts and minds could be won. Equally, if the attending crew had a better way of sharing their findings with clinical advisors, then all parties would learn and feel part of the same team – which we absolutely are.

Ultimately, I signed up as a 111 clinical advisor, not only because I wanted to return to helping the vulnerable and the infirm, but because I wanted to do something to help my ambulance brothers and sisters. I genuinely believe that as well as being an advice service for the general public and the gatekeepers of primary care service, we are the guardians of the well-being of our frontline colleagues.

After all, who is in a better position to care for the carers if not us?

Friday, 19 February 2016

Dear Ambulance Staff: Six 111 Myths and Misconceptions

Dear frontline ambulance colleagues,

After 12 years of responding to 999 calls and subsequently watching from the sidelines as family and friends continue to do so, I am only too aware of the ever increasing pressures and the ongoing erosion of the ambulance clinicians' lot. Poor staff support from within ambulance organisations and the lack of comprehension from government (most recently exemplified by Jeremy Hunt's 'ambulance driver' comment) continues to frustrate me as I'm sure it does you.

I'm grateful for the opportunity the Broken Paramedic web presence gives me, allowing me to keep in touch with the mindset of many of my fellow clinicians on various issues that bubble up in the mainstream media. Thank you for contributing. For the most part, this level of interaction helps me to consider perspectives I might otherwise not have considered, which in turn informs many of the conversations I have with journalists who occasionally contact me for advice and PR-free clarification (not that this relationship moderated the misguided vitriol of certain Mail Online journalists, but lesson learned).

However, when it comes to certain issues, I can't help but notice that there's a degree of misinformation and prejudice which colours some of your responses.

For example, a comment received in regard to my recent employment as a 111 clinical advisor was as follows:

"...Unfortunately, the reality is that you and your colleagues will routinely pass calls to the ambulance service that are nowhere near that serious and you all know it. I think it's fair to say that 111 is despised by many of those in the ambulance service. You're so risk adverse, it's pathetic... Personally I don't know how some of you sleep well at nights having passed the absolute dross you do to us."


In defence of this unnecessarily personal attack, from my own frontline experience I recall how angry I would get when yet another fatigue-inducing shift seemed to have been made all the worse by needless, time-wasting call-outs. I would frequently demonise what was then NHS Direct and also my own service's dispatch staff. Today, it's the medical advice line, NHS 111, which is perceived by many to be a root cause of unbridled ambulance service demand. Discontent under pressure breeds interdepartmental animosity, it seems.

As I've mentioned previously, last year I took up a post as clinical advisor at Hertfordshire's 111 service, a decision I took both out of professional curiosity and financial necessity. I can report the last six months has been a largely positive experience; I once again have the opportunity to directly help those in need and to make more constructive use of my knowledge and experience. Furthermore, it has given me a fantastic vantage point to see the difficulties facing healthcare provision - and they are manifold.

As such, I would like to take the opportunity to address some of your concerns and criticisms in the hope that you consider my viewpoint that NHS 111 is not quite the misguided, incompetent debacle some would like to paint it as. To this end, I have put together a few key facts and 'mythbusters' that might help the likes of Anonymous Angry Commenter above.

One caveat is that my experiences are exclusively based on my time at Herts Urgent Care in Hertfordshire and it should be noted that not all 111 providers have the same resources or working practices. Indeed, Herts Urgent Care tends to perform better than most in the national figures and I do not currently have access to the information to explain any disparity. Further, I don't have the number-crunching resources of the Office for National Statistics and all figures cited have been pruned from sources linked at the foot of this article.

1. The NHS Pathways assessment software is risk averse and sends ambulances needlessly.

The software is risk averse, but not needlessly so. Here's why:

While the vast majority of 111 calls are from individuals with minor ailments or other non-urgent needs, on occasion 111 callers are not always aware of - or prepared to accept - that they may be dealing with a life-threatening condition. As a result, it is not uncommon that people call 111 when they should be dialling 999 or attending an emergency treatment centre. Ideally, every member of public would be able to identify the onset of a stroke, heart attack, severe breathing problem or other potentially major problem, but ambulance staff of all people will know that is simply not the case. As such, Pathways is designed to rule out the presence of any 'red flag' symptoms as quickly as possible so the caller can move on to a more symptom-specific assessment.

It's fair to say that over the phone, this is a potential minefield. The inability to see the patient means that the call-taker is reliant on the information given by the caller. There are a multitude of reasons why this is sub-optimal, and that is the key limitation of telephone triage. While there is of course room for improvement, there is no way to make such a system fool-proof. No call-taker, clinical or not, is going to be able to guarantee they can be 100% accurate in separating indigestion from infarction, stroke from Bell's palsy, or hypoxia from hyperventilation. Not without a physical examination to rule things out.

So sometimes an ambulance gets sent when - even though its recognised that the worst case scenario is unlikely - it would be unprofessional, unethical and dangerous to do otherwise. We cannot not diagnose over the phone, even if every call was dealt with by a clinician.

2. Call handlers are prompted to ask ridiculous and irrelevant questions.

Some of the questions call handlers are prompted to ask during the assessment process can seem inappropriate or unrelated to the presenting problem, such as asking the caller who has been speaking freely during the initial conversation if they are fighting desperately for every breath, or having to ask the mother of a feverish baby if the child has been to a West African country affected by the Ebola outbreak in the last 4 weeks.

However, even though in the vast majority of cases the answer would seem to be an obvious no, imagine the outcry in the rare cases where those factors were in play but no attempt to identify them was made. For the record, both the above-mentioned breathing question and a further question regarding skin temperature are intended to catch signs of sepsis.

3. Calls to 111 are initially dealt with by non-clinical staff.

Mostly true. 111 Health Advisors, a.k.a. call handlers, are largely non-clinical (although there is the occasional clinician in training). They undergo 2 weeks of classroom work which gives them a grounding in identifying more common life-threatening signs and symptoms, but are strictly required to stay within the framework of questions as set out by the Pathways algorithm. Further training is ongoing during their employment and their growing experience should not be discounted either.

Furthermore, the call centre is always staffed by a mix of health advisors and clinical advisors (nurses, paramedics, midwives and other allied healthcare professionals). They work closely together and any call which Pathways wants to send an ambulance response can be checked with a clinician. Once past the initial [module 0] questions - and even during these questions in some cases - any potential ambulance response is verified by a clinician. In many of these cases, the clinician will advise the health advisor to transfer the call to a clinical advisor for 'further probing'. Health advisors cannot deviate from the Pathways outcome (known as a 'disposition'), but clinical advisors can override this, and frequently do when an appropriate alternative is available.

Clinical staff do help out with calls when demand is high and on the one occasion I've taken a call from a paramedic who assumed I was a health advisor, I found him to be quite condescending and rude. He was so abrupt, he didn't give me an opportunity to explain my role or qualifications. Nonetheless, after he terminated the call I did my best to address his request for an immediate GP callback at the scene of a peri-arrest patient with a DNAR. Sadly he went on to make his decision without the GP's (or my) clinical input and I fear he might have made a different choice had he taken the time to engage with me rather than bark down the phone.

Respect costs nothing, even in difficult circumstances, whether you're talking to a health advisor or a clinician.

4. NHS 111 would be more effective if all calls were handled from the outset by clinicians.

There are a number of reasons why this would not necessarily be the case. Notwithstanding the challenges of telephone triage as mentioned in Point 1, the sheer scale of this proposal in the face of the current demand makes the idea impractical.

Last year (2015), nationwide 111 dealt with nearly 1.1 million calls every month. The majority of those calls are for minor ailments, non-urgent problems or other enquiries ('I can't get through to my doctor for an appointment', 'my child has a runny nose', 'can I take paracetamol and ibuprofen?', 'I need a repeat prescription' etc.). It would be a monumental waste of tax payers' money to have qualified healthcare professionals deal with these issues. It makes as much sense as insisting GPs man their own receptions.

Even if it was financially justifiable, the current challenges within the NHS means we hardly have an excess of healthcare professionals to make an all-clinician telephone triage service viable.

To put this line of thought into context by comparing the current climate with that of 111's predecessor NHS Direct, which did favour clinicians as an initial point-of-contact, here's some stats to compare.
  • In 2006/7, NHS Direct's busiest day (23rd December) saw 25,000 calls. An average day in 2015 saw 35,000 calls dealt with by NHS 111. 
  • In 2006/7, NHS Direct answered 68% of all calls received within 60 seconds. In 2015, NHS 111 achieved 91.4%. 
  • In 2006/7, NHS Direct referred 32% of all cases to 'emergency and urgent' services. In 2015, NHS 111's figure was 19% (11% ambulance, 8% emergency treatment centre). 

5. Ambulances are sent even if the caller has refused one.

Within the Pathways process, this is not true. Any 'disposition' [the recommended course of action arrived at by the assessment process] offered by a health advisor can be refused by the caller, at which point the call will be passed over to a clinical advisor.

At this point, the judgement of the clinician takes precedence over the Pathways disposition. Of course no ambulance is going to be sent without good cause and if there is an appropriate alternative treatment pathway, that would be explored - and in many cases it enables us to work with the caller to arrive at an informed and safe decision. However, in certain circumstances, healthcare professionals have a duty of care and may be required to act in the patient's best interests in spite of their preference. We would only do so if there was no other option, and would ensure that ambulance dispatch was informed of the situation.

These circumstances are relatively rare, but with increasing challenges faced by community mental health, patients discharged prematurely without appropriate home support, and other underfunded and buckling systems, it's a sad truth that the ambulance service is the only option in certain circumstances, lest the system abandons these people entirely.

6. Abandoning NHS 111 altogether and leaving the public to decide on the most appropriate treatment pathway would relieve pressure on 999 and other services.

This is hard to prove without actually doing it, but it seems very unlikely. With GP services facing a national crisis, A&Es already overburdened and ambulance service utility spiraling out of control, I would imagine a significant proportion of people who currently rely on 111 and out-of-hours GP services would simply call 999 or attend A&E out of desperation.

I believe some ambulance personnel are suffering from confirmation bias. Every ambulance attendance generated by 111 which turns out not to be as it initially appeared is held up as an example of failure, whereas the thousands of calls which might otherwise have resulted in a 999 call are never seen by ambulance staff.

As stated before, telephone triage is limited, sometimes there is no option but to have a clinician on scene to rule out things which may (or may not) require immediate attention. I'm genuinely sorry that this often means engaging ambulance clinicians who might otherwise be attending more obviously life-threatening situations, but that is a problem created by a lack of ambulance service resources and a growing population of elderly, infirm and vulnerable people, exacerbated by a broader failure of government to provide appropriate support and prevention measures.

Millions of people rely on the service provided by NHS 111 and for most, it is effective and useful. It is something of a Pandora's First Aid Box. Now the system exists and the box has been opened, it is nigh on impossible to put everything back, even if we wanted to. I believe to remove the facility altogether would increase pressure on other services, not protect them. It would be better for ambulance and 111 services to work together to improve the relationship between them.

In conclusion

I accept that NHS 111 is an imperfect system and that it does contribute to the pressure which impacts of the daily experiences of 999 crews. But I hope you will see that there are valid reasons for the calls generated. If there were enough ambulances to shoulder the demand, it wouldn't be an issue.

For what it's worth, I certainly hope to participate in making the process more effective, but even if there was a way to guarantee every ambulance referral was appropriate to the skillset of an emergency ambulance crew (which there really isn't), I suspect it would make little difference to the intolerably high utilisation rates under which crews toil.

The truth is that the general public will always seek the quickest route to solving their problem and healthcare organisations will always try to provide this on the lowest possible budget. There is a lack of high-level foresight in the utilisation of ambulance crews; the powers that be seem to work on the principle that replacing is more acceptable than protecting when it comes to the workforce. The beancounters think an ambulance crew not dealing with an attendance is one that is wasting money. This is compounded by the current ideologically-led efficiency savings suffered by ambulance services and by the competitive market model which 111 providers have to adhere to, creating all sorts of limitations (underbidding leading to cost-cutting measures, private provider need for profit, unwillingness to work openly with potential competitors).

The accessibility and convenience of NHS 111 and 999 services means that initial contact with primary healthcare has never been easier. Along with a growing and aging population, I believe this is the cause of the rise in demand. Like ambulance services, NHS 111 cannot deny the public treatment if there is any possibility that it may be appropriate. Making that determination is the key factor here – what  an individual wants and what they need are not necessarily the same thing. And making that decision over the phone is even trickier than doing it on scene.

Ultimately, 111 and 999 are on the same side and should find ways of working more closely together to deliver the right care to the people who need it. There's little to be gained from animosity.

Of course, if even after taking all this into account, you feel you need to continue scapegoating 111, then I can't stop you. I've been there – sometimes you just need someone or something to kick. But at least you'll hopefully now be doing it from a more informed position.

Sources: Connecting Health and Home: NHS Direct Annual Report 2006/07
NHS England: Ambulance Quality Indicators Data 2015-16
NHS England: NHS 111 Minimum Data Set 2015-16