Monday, 5 January 2009

The rotting system - the Ambulance service

The following piece is from a doctor who has had a lot of first hand experience with the management structures that control our ambulance service. His years of experience and exposure to the problems mean that he can neatly and eloquently describe just how the politicisation of the process is damaging to patients:

"Having recently been binned as a medical adviser to an ambulance service, I might shed some light on events: Paramedics are being encouraged by some management teams to avoid conveying patients to hospital. A good way of doing this is to send a single-manned car instead of an ambulance. This stops the clock ticking and helps achieve the 8 minute target and provides a barrier to conveyance of the patient.

Hospitals are unpopular with ambulance service managements because the ambulance is delayed by the need to drive to the hospital which takes time. On arrival at the hospital, there is often delay due to the ED managers blocking the patient's acceptance until they can be sure that the patient can be processed within the target time. Also, the ambulance then has to drive back from the hospital, which also takes time.

Much more efficiently, if the patient is not conveyed, the ambulance becomes instantly available for the next category A call and the 8 minute target is more likely to be reached for that one too.

Of course, the hospital and PCT managers are not going to discourage any behaviours that result in fewer attendances at the ED.

The classic paramedic training does not equip the paramedic to make an assessment with a view to recommending non-conveyance. The doctors who constructed that course were wise folk who knew that it is much more onerous to declare a patient fit than to send them for further investigation. In a 16-week course that includes a 2-week driving course assessment skills at the necessary level could not be taught.

More recently, extended care practitioners (ECP) have emerged. They do a six-month course having already shown themselves to be in the top group of paramedics. Some are nurses. So this is an add-on course for people who are already experienced, say 3 to 5 years in. ECPs usually work in single-manned cars and they have a limited formulary. In the pilot scheme in Bristol, they seemed to be safe, but they took responsibility for their decisions and it was not a course in high pressure selling of the "say at home" option. Their work was audited.

The episodes described here and the one in Brighton (see "paramedics arrested" topic in the "air your views" forum are simply disgraceful and indefensible practice from bullies in green overalls.

It is essential that each and every incident be reported, because patients are incredibly vulnerable and ignorant of the care they OUGHT to be getting. Only doctors, nurses and conscientious paramedics can make any impact on this. All paramedics have to be registered with the Health Professions Council and they accept complaints in the same way as the GMC.

My favourite incident is that of a friend of mine who was a paramedic in the LAS. He was sitting at home watching the rugby with a can of beer, waiting for his wife to return (A & E sister). He suffered a sub-arachnoid bleed and realised what was going on. He called an ambulance and staggered to the front door to open it and then collapsed. The crew arrived and stepped over him and decided that he was some kind of drunk. Eventually, after he pleaded with them, they dragged him out to the ambulance, grazing his foot on the way, and dumped him at the hospital as a "****ing drunk". He was thus put into a cubicle and left until he fitted, after which he was scanned and sent to ********. The only slight relief is provided by the fact that it was the same crew that attended for his transfer, this time intubated and ventilated. That was in 1988, so it really is time we did something about this type of behaviour!"

The words above make it very clear that this is a systematic problem brought about largely by the mismanagement from the top. The vast majority of paramedics are excellent and brilliant professionals, however the system is rotting in such a way that it is dragging everyone down with it, the small minority of dangerous paramedics will be made more dangerous by the political pressures that they are subject to. It should also be pointed out that the ambulance service is currently massively over stretched with its staff fighting a losing battle, unless capacity is increased by a massive increase in investment.

Most importantly it is not appropriate to offer patients the option of not going into hospital in certain situations, it is very easy to hide behind the cloak of patient autonomy when trying to defend reckless practice, however when someone could well have sustained a serious injury and need urgent medical care it is best to encourage them into hospital rather than pretending it would be reasonable to stay at home to help with the government's meeting of meaningless politically driven targets.


Anonymous said...

The ambulance services are being damaged by the emergence of their equivalent of the practitioner grade, too.

I am a junior doctor with some experience of providing care at public events. In the last few years there has been a noticeable shift from crews of two properly trained ambulance staff (ie para/tech or tech/tech) to ones consisting of someone in green, and a patient transport person with little training above moving and handling and first aid.

the a&e charge nurse said...

So any sensible solution to the problem of ever increasing, and in my view unreasonable, demand for ambulances ?

Remember the number of call-outs already DOUBLED during the 90's

Meanwhile, the London Ambulance Service reported a further 12% rise in alcohol related calls over the last 2 years.
Unsurprisingly New Years Eve was the busiest night EVER (same website as above).

Of course various public awareness campaigns, including the "only one of these is a taxi" slogan have had virtually no effect on slowing down call outs, neither did recent media reports about the service being at breaking point.

Similar futile rebranding exercises have not stopped all the world and his mate piling down to A&E in ever greater numbers (first it was casualty, then A&E and now ED).

So, I ask again Ferret, short of having a BASICS doctor on every street corner how do we feed the 5,000 with 5 loaves and 2 fishes ?

Garth Marenghi said...

You have to start introducing fines for people who waste time and cost lives by calling ambulances for no good reason.

I also think small charges for AE would also make people think twice.

Obviously it is practically tricky to introduce these charges fairly, but it needs to be done.

The politicians won't do it because it would be election suicide.

Unfortunately we have people calling ambulances for minor cuts and people going to AE for minor chronic illness, that won't change until you introduce a disincentive.

the a&e charge nurse said...

But you know, as well as I do Ferret, that minor illness, one of the conditions that could be penalised financially under such a scheme, may in fact, turn out to be something rather more worrying.

According to these reports two young mothers died (of pneumonia) after being told by medical staff to take paracetamol because they did not have serious illnesses.

The whole things a absolute minefield.

Garth Marenghi said...

indeed, it's a veritable minefield.

Problem is there is a generation of spoilt demanding idiots who expect a brilliant instant service for free.

This cannot be provided, as we are seeing now the system cannot cope and something has to be done.

Magwitch said...

In the pilot scheme in Bristol, they seemed to be safe, but they took responsibility for their decisions and it was not a course in high pressure selling of the "say at home" option. Their work was audited.

Lucky Bristol. I was an ECP for nearly 4 years. In that time my work was never audited to my knowledge. There was no on-going training and, after we lost most of the local OOH contracts, no GP support in our Control Room. They're also lucky that they get 6 months "extended" training. Ours was 16 weeks but in reality half of that was so called on the job experience; in minor inury, GP surgery, MEW, etc. The other 8 weeks were taken up with 2 weeks patient assessment and clerking, 2 weeks minor injury, a fortnight tip-toeing through the BNF masquerading as a pharmacology module and, my favourite, how to be a doctor in 2 weeks (8 days really), which, quite frankly, was nothing more than a recap of the paramedic course with a few extra tit-bits thrown in. The main thing we learned was how to saftey-net or cover your arse.

I gave it up in the end due to the frustrations of waiting up 2 hours for a back-up ambulance when I had seriously ill patients suffering in front of me. But because I'd made it to the scene in the 8 minute Government target I and my patient were bottom of the list for an emergency ambulance.

It all bollox. It's all about government targets and bugger all about patient care.

Now I'm back on the bus most of my patients "go-in". My view is that I'm not going to get sacked for conveying a patient.

Garth Marenghi said...


thanks for that, very interesting indeed,

it's unsafe and unfair on the undertrained staff to be putting them in these positions with sick patients, however it result in the targets being hit

roman said...

This sheds more light on what happened to a friend in the Midlands just before Christmas:

8pm, 16mth old boy had been sufficiently poorly during the day to justify making a next-morning appt with GP, but he took a turn for the worse.

Ambulance called, but 'nothing available' so a paramedic came, took one look and said 'I shouldn't be doing this, but get in the car NOW, I'm taking you to hospital'.

Two weeks in a paediatric ITU with a serious attack of meningitis later, the toddler is now slowly recovering.

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