Pre-Report Report

So…

“Da Boss”, Peter Bradley CBE, Chief Executive of the London Ambulance Service also moonlights as the governments ambulance advisor.  As part of this new role he has created a report on the future of the ambulance service.  This report will be published on Thursday, although a couple of his ideas have already been released to the public (the use of ECPs and the changing balance of vehicles).

ECPs are ‘Emergency Care Practitioners’, paramedics specially trained in treating minor injuries.

Mr Bradley is strangely respected by the road crews of the LAS – and I say ‘strangely’ because we tend to be dismissive of anyone who works in an office.  Middle management tends to be disliked by everyone, and upper management is seen as having lost touch with the job as it is today.  But Mr Bradley commands a great deal of respect amongst the troops.  From people who have spoken to him I hear that he is indeed a fair, and forward thinking boss, something that I think we need.

Once I get my hands on the report I’ll do a full breakdown of it, but until then, here are my thoughts on what the media has been reporting.

First off, there is no way the ambulance service can continue in the current way of working.  The number of people using the service are rising, and while the ambulance service was originally for emergency calls, our area of expertise has had to be expanded in order to fulfil the wishes of our clients.

In plain language, we deal with a lot more ‘crap’ jobs.  Because of all these crap jobs, we soon won’t be able to cope.

We have tried to educate the public about the correct use of ambulances, and the NHS has provided other sources of patient information and treatment, like pushing for pharmacists to provide more advice, the creation of NHS Direct, and more ‘Walk-in centres’.  Unfortunately, this hasn’t helped much, and the change in the working hours of GPs has only increased the workload for ambulance services countrywide.

In other words, no matter how many times we tell people we aren’t a taxi service, and give them other ways to get treatment, they still want a ride to A&E in a big white taxi.  GPs refusing to work during the hours of darkness (or hours when the golf course is open) hasn’t helped us much either.

So, the ambulance service needs to think smarter, rather than throw resources at the problem.

We surrender.  The public are too daft to be told.

The plan is simple, we bring treatment to the patient, rather than bringing the patient to the treatment.  A&Es are busy places, and there are a lot of patients who can safely and effectively be treated at home.  Other patients will be advised of other, more appropriate, avenues of treatment.

Taking everyone to A&E only increases hospital waiting times, which are no good for anyone (let alone government targets), so why can’t we treat things like minor wounds at home?  We should also be able to tell people with a runny nose that they need tissues, not an A&E department. (We do at the moment, but the service doesn’t currently support us doing this).

The ambulance personnel that will undertake these roles will have to have extra training.

Here is the problem, it’s all good until someone gets left at home and then dies.  Training will have to be pretty intense, and that will cost money, and take time – there will also have to be some serious support for people acting in this extended role.  When every job could ‘go bent’, I imagine the stress will be pretty big.

The salaries of those trained will have to increase.

Because a majority of calls to ambulance services are not life-threatening emergencies (my opinion only), the balance of solo responders (like myself) will increase, while the number of ‘proper’ double crewed ambulances will drop.  Of course, if these extended role practitioners feel the need for a patient to go to hospital, if appropriate they may transport the patient themselves.  (This is why all new ‘Rapid Response Units’ are going to be people carriers).

This is really brave.  With enough ECPs I think that this will work.  But I wouldn’t like to work in the PR department the first time the Daily Mail has the headline “Ambulance chiefs send car to dying wife”.  Also with more people turning up alone to calls, I suspect that there will be more and more risk of ambulance personnel being assaulted.

The plan is to send these rapid responders to more calls, so as to filter out and treat those people who do not warrent an ambulance.  Then ‘proper’ ambulances will be reserved for the most serious cases.

My personal opinion of what I’ve heard?  I think it’s a bold, yet very clever idea – and I hope that it will work.  I think that success will depend on the details, like what the training is like, and I hope that the government doesn’t water down the ideas.  We will also need some serious thought going into treatment guidelines and protocols in order to protect the registration of paramedics.

At the end of the day – we are cheaper than GPs, we work 24/7, unlike district nurses, community psychiatric nurses and GPs.  It is up to the ambulance service to pick up the shortfall in care that this leads to, and ‘Da Boss’ is thinking ‘outside the box’ to solve this situation.

I’ll write more once I’ve read the report.

18 thoughts on “Pre-Report Report”

  1. Well, emergency rooms in the States here get dumped with all the crap jobs, and are running out of money, so this is one possible strategy. Insta-cares are also expensive, but tend to take the “crap” cases 24/7 or at least 18/7 which is still better than the GP offices most of the time. Unlimited need-limited resources, folks still want care when they feel ill. Care givers still want their own lives once in a while. No simple solutions.

  2. Look forward to reading your full thoughts and seeing how, as someone on the front line, they differ from the knee-jerk reaction of the press and politicians.Nugget

  3. so we've all heard about the ECP role using paramedics with the pre-hospital experence, but why not turn it on it's head and use Nurses to NURSE people at home, ENP's do it in the A&E department, so why not out of it?

  4. Tom, Yes it's an interesting idea & you write about it in a constructive way.You raise the concern about the personal safety of staff responding; I wonder about the further risk to them of having to make judgements about a wider range of complaints solo (which of course you already do in your role as RRU), and the concern about accountability, liability and later complaints from disatisfied customers, as might happen in the US, where there seems to be a small industry in lawsuits claiming bad care….

    / d b in chicago.

  5. You mention that the new RRUs will be “people carriers.” I'm trying to picture this – are the RRUs still going to be cars but have room for a paitent (so, in essence, they are taxis), or is Ambulance service going for a larger vehicle of sorts?

  6. One interesting point is that people die on a daily basis. If solo responders are going to leave patients at home there will inevitably be deaths that would occur that are not related to the actual initial reason for calling. So, whoever responds probably goes way overboard and checks as much history, vitals etc as possible to 'cover themselves'. The result: an ambulance or car that is tied up for a period of time which actually exceeds the time taken to drop the back step and say 'get in?','name?','DOB?','go and book yourself in at the reception desk','cup of tea mate?','you'd never believe what X did the other day….','that time already, throw the clear in'From a time perspective it is often quicker to fill the waiting rooms with crap.

    From a responsibility perspective it is often safer to fill the waiting rooms with crap.

    From a patients perspective it's time to change.

  7. A “people carrier” is a British term for a large car, such as a Toyota Previa, Ford Galaxy or a Vauxhall Zafira, or other similarly-sized vehicles. They are normally designed to carry 4-7 passengers, although they could have seats removed to enable them to carry more kit.The picture right of centre on the LAS's home page:

    http://www.londonambulance.nhs.uk/

    is of what I think would be considered a people carrier.

  8. It sounds very sensible in theory.I wonder what the impact will be on people asking for treatment following self harm (well, it is my area of interest!).

    Will the specially-trained paramedics spend hours going round stitching people up? Will an exception clause be introduced?

    I have never called an ambulance for myself. Then again, I can drive and I have a car. I still think of ambulances as being for life/death situations.

    Cat

    (purplepiranha.blogspot.com)

  9. It is infuriating, the situation at the moment. We too often see people brought in, NOT in labour, in an ambulance that they shouldn't have called.Was thinking about this last night. Sometimes people abuse the system but other times they do not have a choice; what about people who can't drive or are on their own, in labour, with no money for a taxi? As someone who has been in that situation of having literally no money I can say that this DOES happen. What are they meant to do when they go into labour? Our midwives say call an ambulance. But they are not emergency cases.

    We were thinking maybe there should be a voucher system for those on income support, where they can have a taxi voucher for when they come in in labour, thus meaning they will be able to get in and stay safe but won't waste the time and money of the ambulance services.

  10. Why not? Probably because ENPs cost more money to employ, and they don't have the pre-hospital experience that we have.Also, ENPs are the ones who are training the ECPs, but won't be ECP 'qualified' themselves, so there is probably some difference in the training.

  11. You are right, it looks like the Vauxhall Zafira that will be rolled out to replace the current Vauxhall Astras that we are using at the moment.Apparently Zafirias are really easy to roll over if you take a corner too fast, something we are have a habit of doing…

    When we get more vehicles, I'll run a book on who'll roll one first.

  12. I vaguely allude to this problem when I talk about the support that the LAS will have to give its staff. There is a rumour that a crew has been suspended, one week after a patient they left at home died of unrelated causes.If this is true, then there will need to be a serious rethink on how such cases are handled. I think the proper report may address this problem.

  13. The plan (as I understand it) is that there will be three times the number of cars, but only half the ambulances, this may account for the longer time spent on scene.But yes – in my eyes it's easier/quicker to take folks to hospital, no-one ever lost their job for taking someone to hospital…

  14. Well.Most self harmers I come across don't need stitches (which is perhaps a bit of a trite reply, sorry it's not meant to be), so I don't think it'll be hours, no more than any injury. the thing about self harmers is that they go to hospital, not because of their wounds, but because of the need for a psychiatric assessment.

    So I suspect that self harmers will still be taken to hospitals (if only because I don't have much faith in CPN services).

  15. Well…I think it'd just be more cost-effective if we forged links with local cab firms, gave their drivers a vague clue as to how close labour is – then send them, and they call us if we are needed, otherwise they take the 'patient' into hospital. Then we pay the cab firm the fare if the patient has low income.And I too, also know the pleasures of being without money. Dog bone soup anyone?

  16. Hello Tom,I can't let this one pass. I am a CPN and where I work we do offer a 24 hour service. Admittedly, it only started several months ago. We have had some of the ' trainee' emergency care practitioners with our team for one day placements. It does look good but I worry that senior managers and the government will realize how much it could cost and go for a cheaper option.

    Good Blog and I enjoy reading about your adventures in the big smoke.

    Cheers,

    Decko.

  17. Would you feel comfortable driving a car with just you and a patient, or you a patient and one of their relatives? Especially with all that kit on board (sharps, drugs and so on) I'm not sure I would.

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