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
The episodes described here and the one in
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.