‘Cheating’ To Get Care

I've mentioned before about how we in the ambulance service have procedures in place for the elderly who we suspect of being at risk. If there is a risk of abuse or violence then we can fill in a form, fax it off to Control as soon as we reach a hospital and the team in Control will make sure that Social Services are made aware of our concerns.

It works pretty well to be honest – I've done a couple of these 'vulnerable adult/vulnerable child' referrals and have gotten good feedback on most of them.

Unfortunately there is no easy way to alert social services to a 'non-emergency' cause for referral.

We were called to an elderly lady who had gotten out of bed and had slipped. She had fallen on the floor and couldn't get up. Also in the house was the woman's sister, also in her eighties. Her sister had tried to help, but the patient was heavy and the sister was frail. Our patient was stuck.

I'm more than happy to go to these sorts of calls (a 'Nan down' call) mostly because if the cause of the fall is a simple trip or slip we can pick them up, check them for injuries and more often than not leave them at home. The patient is happy to be off the floor and not being dragged to hospital, and we are happy because we feel that we have done something useful for a change.

In this case it was a simple slip that had caused the patient to fall and she had not hurt herself. We picked her up off the floor and after an examination were more than happy to leave her at home.

I asked the patient and her sister if they had any carers, anyone who came in and helped them with the day to day stuff. She replied that there was a district nurse once, but that she had disappeared without doing anything.

With my inexpert eye I looked around the flat. I could see where some handrails could be useful, where some modifications to the bath could improve safety and where a better bed could prevent a recurrence of the fall. The patients could also do with a community alarm.

(Community alarms are great, the person wears an alarm around their neck and if they fall over or get into trouble they can activate it and we turn up to help them).

So it appeared that someone had been there once, but since then the sisters had dropped off the radar.

There was no way that I could justify filling in a 'vulnerable adults' form for this, they weren't 'vulnerable' they just needed a proper assessment to provide some things that would make their life that little bit easier and safer. If I filled in one of those forms it would take time and resources away from those who really did need immediate action.

Unfortunately I'm stuck – we have no pathway in place to involve social services in any way other than in an emergency fashion. Our Emergency Care Practitioners can refer patients to social services, but only if they live in certain postcodes (where PCTs fund the ECPs – it all gets horribly complicated).

The LAS could do with improving this – we need a way to bring patients to the attention to the social services that doesn't require it being an 'emergency'. Lets face it, we see hundreds of people each day (around 4,300 calls each day at the moment), who better to keep an eye out for people who might be at risk, yet who haven't yet had any social services input?

Maybe the social services don't trust us to to their job for them? Maybe they are so over-stretched that they can't deal with a raft of new referrals that we would make?

Well – in this case I've 'cheated'. I gathered the patient's details, spoke to a friendly receptionist (actually all the receptionists at the hospitals are friendly) so I could get the GP details and I've now written a letter to the GP detailing my concerns. I've done all I can do about this situation which means that I can sleep at night, but wouldn't it be better if we didn't have to 'cheat'.

I hope that the GP/social services doesn't get snotty – I hate having to shout at people…

24 thoughts on “‘Cheating’ To Get Care”

  1. very good point batsgirl. I can imagine this scenario happening often. So I guess we will always need Reynolds' (plural) to cut through the paperwork and just get on with the common sence approach. Sorry mate, not what you get paid for but maybe what you do best.

  2. When I moved to the US from Britain, a distant 14 years ago, I vehemently resisted the use of that word. I'll admit, though, that sometimes it's just the best word for the job (unless you want to sound terribly snobby). I've gotten used to it šŸ™‚

  3. I applaud your cheating and hope something comes of it – however the definition of social services is “overstretched”, usually.Also, in my experience, little old ladies after a fall are a bit shaken and have to admit that they're in a bit of a vulnerable position and have trouble with certain things and could do with some equipment to make their lives easier. And they can bring themselves to admit this to the kind person who has helped them up and seen to it that they are okay.However when some person wielding a form and clipboard comes into their home and briskly – or worse, patronisingly – says “sooooo… you can't do this, you can't do that, you're too old to do this, too frail to be safe with that and too weak to manage the other?” then pride takes over, that old “we coped through the war” spirit comes through, and there's a temptation to raise one's head and tell them that you're managing just fine, thankyou. At which point the assessor (who hasn't seen them on the floor and is rather pressed for time) writes down on their form that the client says they have no problem with stairs, no problem getting in and out of bed, no problem preparing a meal, and they are managing with the bathroom and getting dressed and so on… the form is processed and the little old ladies get none of the stuff they need.I'm only guessing, obviously, but I wouldn't be at all surprised if this was what happened with the district nurse.

  4. It sounds like a great way to get around a broken system. We have similar problems in many parts of the states but we have this nagging law called HIPAA that prevents nearly anyone from giving any info out without reams of paperwork. If we tried to backchannel like that there's a good chance we'd end up on the wrong end of a lawsuit. It seems that these kind of people fall through more than just one systemic crack and the systems that are there to help them are actually, in many ways, self-defeating.I hope that any adult protective services / child welfare complaints I have made were followed up but it's not hopeful when you can only ever speak to a machine. There needs to be something that can cater to those that aren't in imminent danger but need some additional community support.Anyway, great work Tom. If there is one thing that EMS people are good at it's adapting to flawed systems in order to act as advocates for our patients.

  5. And as the GP's receptionist who opens the letters, we make a point of not only 'processing' the letter but actually saying to the GP 'have you seen that letter about Mrs. such and such? Are we going to refer to occupational health/social services/necessary person?Sadly as everyone knows the services are all very overstretched, but when things like this are pointed out I know that we do our best to make sure that referrals are made. However Batsgirl is so right with her comment about the 'I will cope with this I survived the Blitz' – can you imagine our teenagers of today in 70 years time with that attitude? No, I can't either.

  6. I'll agree with Jamie. In our rural part of the EMS world, there is often a very grey area that exists when the elderly fall into the gap between 'just about able to take care of themselves' and 'not so unwell that the State will admit them into a care facility'. We frequently become the only assistance that these patients can rely on. Often we'll have a 'frequent flyer' with relatively minor but recurring problems that we'll get called to. In one case we were getting toned twice a day to one LOL in town for ailments such as 'patient is confused' (she lost her cat). Eventually the State finally realized that she couldn't take care of herself any more, and they found a place for her in a care facility. That's one of the happy endings. Many aren't.I recently read an article (in JEMS I think) by an EMT-P regarding opportunities for educating patients with Diabetes. It is the job of EMS, he suggested, to not just pick them up and give them glucose when they forget to manage their condition – but to also take the opportunity to evaluate their diet, medication and lifestyle and suggest improvements. There's a split between people in EMS who think that 'this is not our job', and those who feel that any opportunity at improving a patient's quality of life shouldn't be wasted. There is a fine line between a quick helping hand, and becoming over involved.

  7. You did totally the right thing. The fault is with the system. The ones at the top have never seen the evryday people they claim to be helping. They were norn into high circles and their only experience of the suffering of the likes of these dears is whatever they read in a textbook.Listening to someone with street experience is beneath them. Besides. they know it all already. After all, the books they read told them everything they need to know.

  8. Exactly. The problem can often be that prehospital providers get sucked into a “not my job” kind of attitude because that is often the attitude of more single-goal-minded (does that even make sense?) services like firefighting and law enforcement. The thing is that it is EXACTLY our job. I tell my students that hte job on being an EMS professional boils down to one thing: act as a patient advocate. Cleaning the trucks? Patient advocacy. Calling an APS referral in? Patient advocacy. Covering grandma with a blanket? Patient advocacy. It's sometimes hard to convince our colleagues that our job is much more complicated than lights and sirens and pointy needles.

  9. The thing is that we then start stepping into the areas of other people. Other people who are better trained than us in their own field.I'm no expert on long-term diabetic care, although I find the emergency stuf easy enough. Should I then have to take the place of a GP, even though I don't have the training in endochrine disorders.

    So it's a good idea, but only if you are trained in such things.

    As I often say to my patients, 'I'm not sure what is wrong with you, but if we take you to hospital then the doctors will be able to work it out'.

    Otherwise, where do we stop?

    Of course, we now have to do Blood sugar tests on everyone for 'pre-diabetic screning'.

  10. I agree with Tom on that point but with the caveat that the scope of our responsibility changes as more and more people use EMS as primary care.Are you really doing blood glucose checks on everyone? Sounds like a crazy use of resources considering how much test strips for some meters cost.

  11. I hope no one gets snotty either. They damn well shouldn't.But Tom. just a minute, what is your local social services thinking of? They should take a referral from ANYONE, neighbour, bystander, and certainly a paramedic.

    Do you mean that if you – even personally – drop SS a note saying “I am very concerned about Mrs Bloggins because she is frail and living off cat food” they are going to IGNORE your letter because it has not gone through the “normal channels”?

    Oh God, just a minute….. there isn't a PROTOCOL now is there for referral to social services? ARRRRRGH!

    John

  12. well, I'm a mere five years older than “teenage”, and I've hit frailty several decades early, and while it's been drummed into me due to the sort of work I used to do that if I don't answer forms and doctors *honestly*, then I won't get the help or treatment I genuinely need, I still cope with more and do more than my family and friends really want me to.Please don't tar all young people with the same useless/lazy/good for nothing/feckless brush.

  13. Lets put it like this…ECPs who are employed by the PCT have Pathways for referral.

    I don't as I'm not an ECP, nor am employed by the PCT.

    Now you know what I mean…

    But, yes, they shouldn't moan – and if they do they'll find that I can moan even louder. I can get rather bloody-minded about such things.

  14. Oh – and the leter was to the GP as they should know the patient (and any care assessment that has gone on before hand).Given the state of some of our GPs I wouldn't be surprised if they got the hump with a mere EMT bringing something to their attention.

  15. I bloody love your blog, and I'll probably buy your book. It's brilliantly written.However…

    I can't handle your use of the word 'gotten'. I really can't begin to tell you how much it upsets me, as an Englishman, to see a fellow Englishman – a really intelligent, literate one – use it in a sentence as though it's ok. It's so, as Americans might say, not ok.

    Rule Britannia etc…

  16. Ah, but see – I write how I talk. Barely understandably.So what *would* be the correct term?

    (Willing to be taught)

  17. My first thought was “Age Concern” when I read this story. If you follow this linkhttp://www.ageconcern.org.uk/AgeConcern/local.asp

    And type in London, you get the contact details for all of the London based branches of Age Concern (there are 32 – I don't know where you are based in London). Maybe you could print a list of the nearest ones to you, and next time you visit a vulnerable old person, leave the freephone number with them. Age Concern will know exactly what resources, charitable and otherwise, are available to these people.

    Keep up the good work, it could be us one day.

  18. In this case, it's simply “got”.”the lady got out of bed”

    or you could use a more descriptive term such as climbed, clambered, eased herself out of bed.

    In the case of “I've gotten used to it” I think it would be “I've become used to it”.

    But then, I blog as I speak too. The crap I type is lucky if it gets looked over more than once for typos.

  19. You didn't cheat to get care, you contributed towards making a referral to social services.Unfortunately there are so many out there who, although not in need of personal care, do need some assistance to live more safely within their homes. Until we're made aware of them though there's nothing we can do to help.

    Oxfordshire social services will receive referrals from any source, be it a GP or someone's binman. Once the referral is made to SS by your friendly receptionist the ladies will be contacted within 48 hours (cos that's the law) and an assessment made of their needs.

    I don't think you could have done much more to help them, referrals like this are two a penny and they'll be well provided for once they've been made known to the local authorities.

    You should have entitled the entry “a good day's work”…

  20. Sytems and processes are there to be circumnavigated, I often think this is a sign of someone doing a good job and it sounds like these ladies would benefit from an OT assessment and maybe a limited care package. While true that social services are overstretched, they do have to respond to a referal, and this is all much cheaper than placing someone in a care home so have some confidence that your actions will be rewarded by a response!

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