The Post That May Lose Reynolds His Job…

(…Or At Least Means He'll Never Get A Promotion).

Let me start with a few assumptions.

(1) Ambulance workers are human beings, human beings require food.

(2) The government wants the NHS to spend less money.

(3) People who use the NHS have high expectations.

The problem.

There have been a lot of stories in the news about people dying because of 'Crews on rest breaks' and even one where the proliferation of solo response FRUs are questioned as well.

To answer the first story – it was unfortunate that the people running Control put two crews on a break at once, I'll suggest why this may have happened later in this post. To quote the LAS response to the death,

An LAS spokesman said: “We dispatched a rapid-response car, which arrived at the shopping centre within eight minutes at 1.30pm, the member of staff being able to start treatment immediately. An ambulance was sent at 1.32pm after it became available from attending another incident and, according to our records, arrived at the shopping centre at 1.41pm and at the patient a few minutes later.

So, within eight minutes a solo paramedic arrived and nine minutes later there was an ambulance, so the maximum time the patient waited was seventeen minutes. Without knowing the circumstances I would imagine that even if a crew had been sent from Edmonton station they would have shaved only three or four minutes off that time.

The crews on the meal break wouldn't have even known that there was a call, Control are under orders not to disturb crews except in the last 10 minutes of the break.

Here is the thing – The press love this story because it points blame at the crews, our management or even EU legislation. Here is the story that you don't hear every day, but would be much more common.

'Man dies waiting for ambulance because they were all out dealing with idiots who call up for a stubbed toe that happened two days ago'

But it is harder for the press to prove that the reason why there wasn't an ambulance there in minutes was because they were run ragged chasing after mis-users of the service.

On the breaks themselves – in a 12 hour shift we are paid for 11 1/2 hours, we have half an hour unpaid break and 10 minutes that are interruptible. If our break is interrupted in those last 10 minutes then we receive a payment of £10. This replaces the old system of having our breaks 'bought' off us for £7.10 and while we would often be able to 'sneak' a meal, it was actually a disciplinary offence to do so. With increasing work pressures this was getting harder to do. These breaks must be completed within certain hours.

Why mealbreaks are impossible.

So – what is the problem with providing workers with mealbreaks?

Year after year the ambulance service has been put under increasing pressure. We have increasing numbers of calls. We are expected to provide services that were once the domain of GPs. More people are calling us for non-ambulance work, the recent stories about some of the rubbish we go to on a daily basis are just skimming the surface of what we do every day. If we look to reduce the numbers of inappropriate callers then, as Magwitch notes, the press is up in arms.

We do not sit on station playing pool or sitting with out feet up – we tend to go out in the morning and not stop until the end of our shift.

Then we have the pressure from the government, first they tell us that we have to get to Cat A calls in eight minutes, then they change the goalposts (Now we'll have eight minutes to get to the patient from our Control picking up the phone, rather than from knowing where we are sending the ambulance). Then the government tell us that the NHS needs to 'make a profit', whatever *that* means. Despite the increasing number of calls and our increasing roles we have less money than last year to cope.

Patient care is going to suffer as we seek to please the government.

The government therefore want us to do more calls, with wider roles but with a lot less money.

They sit in their ivory tower dictating what they want and the ambulance service bosses say, “Yes we can do that”. If we don't do it then the money is cut even more. You never hear the government suggest that maybe we need more ambulances to cope with the increased roles.

Due to the budget pressures we have been put under recently there was essentially no overtime available. While we are supposedly fully manned it still meant that there were plenty of ambulances unstaffed. This situation was brought about by the government cutting our money, all at the risk of patient care.

When we have to provide the government with our response time figures we'll flood the area with ambulances so that we can make it in a 'big push'. Budget be damned. It used to be if we didn't make the target then our budget would be cut – now they cut it regardless of us making our targets.

And so we flip-flop, from saving money to providing more ambulances and back again. Our management are on the government leash and are being pulled in two directions.

This may explain why two crews were put on break at once – because management are under pressure from the government to save money wherever possible they are trying to get us our full breaks (in limited time windows) because we can't afford the £10 for an interrupted break.

So the short version – We don't have enough ambulances to to provide the care that the public and the government want and the introduction of meal breaks has just shown up how stretched we are.

And for some reason our bosses won't admit it.

A solution?

So what can we do? People are not happy with the service so there are three ways to deal with this. One way is to lower the expectations of the public toward ambulance care (and perhaps the NHS in general). If the public considered themselves lucky to get an ambulance, then they wouldn't complain so much, this is the attitude I often get from people who weren't born and raised in the UK. But there is no way to do this, and we shouldn't – we should expect, and get, top service from the NHS.

The second way is to reduce the number of calls we get by streaming out the 'crap' or by educating people about the misuse of ambulances. This isn't simple and would take twenty years or more to implement. Fines or paying the cost of the ambulance would sit in this camp and, as I've mentioned before, I don't like the idea of paying for ambulances because it would frighten off the poor.

The final way is for the government to give us more money and to stop pulling us in two directions at once. This isn't going to happen, the motive behind Patricia Hewitt's desire to 'make a profit' is that they want to invest less in the NHS. I'm not suggesting that we need to throw money at bad services, but there does need to be an increase in funds. If you were running a business you wouldn't expect to be able to expand your company without some form of investment.

But what can we do to force the government to listen to us?

Here is my solution. When the government asks for response figures we refuse. We stop recording and collating them. We spend the money that we have on improving patient care, not on fanciful imaginary 'performance indicators'. We make a stand against the utter idiocy that is the Department of Health. What could they do? Sack us all? It needs to be countrywide and across every level of the ambulance service. We need to be bloody-minded about making the government concentrate on Patient Care and not fulfilling their seeming desire to run the NHS into the ground.

We need to take a rolled up newspaper, strike across the dog's nose and in a firm and clear voice say , “No!“.

It may be simplistic, but it's the only language they understand.

85 thoughts on “The Post That May Lose Reynolds His Job…”

  1. I'm not a big fan of ambulance services going on strike for reasons too numerous to mention.I'd *hate* to strike, all I suggest is that we stop giving data to the government in order to hang us and instead concentrate on what is most important – patient (and staff) care.

    (And I decided against mentioning the billions spent on useless wars and weaponry because it's a point that has been made too often – with good reason).

  2. I don't know how the LAS works and the prices they charge (i haven't been following your blogs for that long…unfortunately!) but here in Sydney the Health Services Union (of which ambulance officers are a part of) have been known to have 'paperwork bans' where we fill out our casesheets for each job as normal, file them on station but don't send them on to head office. Therefore they receive no stats, or any patient information and therefore unable to charge anyone we attended. This usually results in pretty quick action.I think your 100% correct in suggesting misuse of ambulance resources is more often the cause of delays in getting crews to people who are…actually sick. I get some sort of sick satisfaction reading your blogs and knowing that it also occurs in such frequency over there though and not just here hehe. This public perception that there are ambulances on standby for them around the corner 24/7 and that calling out an 'emergency' vehicle for every minor affliction known to man is OK needs to change.

    As much as i may get slightly annoyed with peoples attitudes about this is it any wonder they do? I mean with no education or ad campaigns to promote what we are there for, when to call, who we are, can we really blame them? I can't speak for the LAS but here there's absolutely nothing, unless you purposely go looking for it.

  3. In the US, people have to pay for their ambulance rides; within our specific county, it's 500 bucks a pop for an in-county resident, plus an additional fee per mile. 600 for out-of-county.Even so, by no means do the poor shy away. 70% of our calls are still the homeless regulars, the drunks, and cold/flu-like symptoms.

    EMS is here to help you when you're seriously down, not to wipe your nose. The public doesn't understand this… and frankly I would go so far as to say that more have died because of time-wasting calls than that would die if they were concerned with the cost.

  4. As an aside, and not wanting to divert from a very important topic (great post btw), but i just wanted to comment on:“We need to take a rolled up newspaper, strike across the dog's nose and in a firm and clear voice say , “No!”. “

    Dog training has moved on a lot since the days when we though hitting dogs, or rubbing their noses in excrement was going to help in any way. Reprimand after the event (even just seconds after) as you describe, is not just useless, but also very counterproductive and actually serves to reinforce the behaviour. If you want to strike people at the department of health on the nose with newspaper, and say “no” in a barbara woodhouse voice, that's fine by me (especially if i can come along to watch!), but the metaphor you use would actually encourage more abberant behaviour rather than deter it.

  5. LOL “hearts” – what's that Sod's Law about correcting other people online? It got me, anyway!While I'm here, how about the idea that, teaching basic survival skills for the individual and their fellow people is more important than teaching algebra, which my life hasn't since relied upon in any meaningful manner, and suchlike?

    The kind of people whose brains can naturally love and absorb that stuff will find it anyway – it's what people do with a thing they love, be it reproductive habits of the reptile, or the teachings of (insert prophet name) or the best kind of shoe to be wearing this season.

    Not dismissing those subjects, just making the point that schools teach a shedload of cr4p IMO that does nobody any good, and doesn't meet the needs of the people who will, through personal preference and/or natural talent, go on to excel in that field.

    “Against School” by John Taylor Gatto http://www.spinninglobe.net/againstschool.htm about sums it up for me – sorry I can't make that clickable, but it's worth a read IMO.

  6. Great post (as usual). Sorry if someone else has already said this, but here's an idea for a news headline:”Man dies because ambulances were unstaffed due to lack of funding”

  7. Well done for raising this… I get annoyed by the (very few members of the) general public's incessant demands from the NHS, and their completely rude attitude to the service and staff. I get annoyed the way staff are treated and the little money there is to be spread around. I get annoyed by the media's misrepresentation of the goings on, and further disillusioning the public about the NHS.I equally see my mum, who works for the civil service and is facing 'relocation' (ie redundancy) in a year or so's time. So, ok… nothing much to report, another government-funded department making staff redundant. Another government department repeatedly giving out over-time each weekend. And why is the overtime being given out… targets.

    I was lucky enough to spend a considerable amount of time last summer in far eastern parts working public hospitals. The patients were so very grateful for the service they received. They had to pay for parts of it, but it was mainly publically funded. And even though I did work experience there, I wouldn't have wanted to be a patient… it wasn't a patch on the NHS! When will the public and Ms Hewitt get a grip of what emergency means, what emergency does (ie, gets there as quick as possible… no matter what targets are made). Not stubbed toes…

    The NHS is one of the most amazing things this country has, the government (ok… maybe a select few) is trying their hardest to privatise the lot (give them a few years). People, take pride in your country, take pride in your NHS, take pride in your health!! 🙂

    (From a slightly disillusioned student…)

  8. I stand corrected, although for some reason it worked wonders for my dog, I only had to tap him twice before he associated the sound of rolled up newspaper with being naughty, then it was a switch to the 'disappointment' model.Besides the metaphor also fails because with my dog it would be a tap, while with the DoH I'd need a run-up to get the right amount of force behind it…

  9. the army covers Fire Brigade strikes, the Police (and for that matter Prison Service) can't strike- what would happen if there was an ambulance strike? Not that I'm saying you shouldn't (I am right, this is what you're advocating, yes?), just curious.Of course, the option of “not spending billions on weapons that the intention is never to use” thus freeing up said money for public services is far too radical.

  10. This is one of those tricky situations where it seems like no one can win… I'd hate to have that kind of pressure and discouragement.

  11. I'm sorry for posting out of order here, but, though I looked diligently, I couldn't find a contact email. Perhaps it was removed due to a steady stream of the sort of correspondance that is to follow: in which case, I apologize.I've been an EMT in the United States for a little over a year now. I'm also in college, studying public health. One of the issues we tend to hash (and rehash) quite a bit is the comparison of health systems in the US, Canada, and Britain- and their huge differences.

    When I stumbled across your (well-written, informative, and exceedingly interesting) blog, I was pleasantly surprised to see a lot of familiar jargon and procedures. I was also really interested in the way your entire EMS system is run in relation to the NHS- a very different way of going about things than in America.

    There is actually a point to this whole thing, namely: does LAS allow for observers to ride-on for a period of, say, a few weeks? There are many summer research grants available to students, and I would love to come to London and see first-hand what really happens. (I work in Baltimore, a smallish city with largish problems of drugs, violence, and racial tensions – which seems quite similar to many parts of London these days.)

    Anyways, regardless of whether or not this might happen, I want to send some support from a sister EMT and also to say that this is a great blog, and your book is not half-bad either!

    Best regards,

    Olivia Kennedy Helprin

    Nationally Registered EMT-Basic

    Equipment Lieutenant, Hopkins Emergency Response Unit

    Baltimore, Maryland

    ohelpri1@jhu.edu

  12. Hurrah! What an informative, well thought out and incredibly well written post. I too have been reading the headlines of late regarding crew mealbreaks and it's something we dispatchers have been discussing throughout our shifts over the last few nights.Your post really hit home a major issue for me. Educating the public is something I've been hammering on about for years. I've worked for EAS for more than 5 years now and I've seen the call volume go up at an alarming rate, yet the numbers of ambulances does not match the rate of increase.

    It's all well and good for us to be expected to have no patients waiting, to have “cover” over all areas in preparation for the next call and to ensure that all those crews that are working get their mealbreak that, as far as EU regulations go, they are entitled to. But when the calls we are being expected to attend are as trivial as cut fingers, coughs and colds and (in one recent case) a mishap with a sex toy, is it any wonder something is falling flat?

    In one of the newspaper articles they talked about the number of solo responses now in use and that they were simply being used to “stop the clock”. Ok, yes, in many cases they are, but with so many of our solo responses now being ECP trained, they are responding to and treating at home the crap that has no need for an emergency ambulance whatsoever.

    It tires me out to think about it but I always end up coming back to the same point. Education is the key. People need to realise that the ambulance service and the NHS as a whole cannot feasibly cope with trivial matters than can be dealt with by other means. Common sense seems to have gone out of the window and many ambulance staff are sure to follow if they are expected to keep up with these mounting pressures.

  13. Hear HearI was interested in your comment about expectations. I've been talking about the very same thing in a police forum. The public have been sold an idea that ambulances will appear the instant someone has a shiver, there will be a police officer on hand every time little Johnny turns his stereo up a bit too loud and that our lives will be enhanced by having our bins emptied fortnightly instead of weekly.There is a department in every police force that has only one purpose and that is to supply statistical information to the Home Office. If that department were to close tomorrow, it would make not one iota of difference to the level of service that the police provide, but it would instantly starve the Home Officer of the food they need to survive.It's got to be worth a try, but which Chief will be brave enough to be first?

  14. Al, I don't think stike action is being advocated. What is being advocated is that the ambulance services (i.e. management) stop collecting (meaningless) statistics for the government, and use the time and money saved on initiatives to improve patient care.If I'm going to be treated and/or driven at high-speed to hospital, I would feel a lot happier if the persons treating me had been properly fed and rested during their shift.

    Isn't an answer to put one some of the whitehall mandarins and/or politicians out as observers on a few shifts?

  15. Bravo!Yours is a voice that needs to be heard. I have friends who have been discussing this issue after reading the newspaper reports (such reports are why I gave up reading tabloids years ago). They have been up in arms about “people dying because ambulance people are on a break”. It isn't until I direct them to your blog that they hear the other side that they do change their tune.

    I shall be forwarding this particular blog entry to every person I can. The voiceferous few must be educated!

    Keep up the spectacular work you do.

  16. Solution 1: Not gonna happen. The self-centered scum keep expecting and demanding more.Solution 3: Not gonna happen. The lower echelon would be happy to go about it but a director who still has a chance at further promotion (and payments to make on the car and house) isn't going to jeopardise it all.

    Solution 2: Abso-fuggin-lutely. A brief public service announcement campaign could do wonders. Charge the idiots the full costs plus a fine. That'll work well and the crap tabloids will have a hard time complaining about such a scheme.

    And yes, it needed to be said. Unfortunately you're too low on the totem pole to say so with impunity.

  17. It's the same in every organisation, whether private or public. Everything is measured in figures, not results. Price, not value.Sack? No promotion? Tom Reynolds for Health Minister I say.

  18. well i think it a clear, well thought out post. that says what other ambo crews have been saying on forum for ages.nothing is going to change unless, everyone stands up (public and ambo crew) and shouts “WE NEED YOU TO FUND THE AMBO SERVICE RIGHT, We will not take ambulances sitting doing nothing due to there being no money”The Government should look at there spending, God know how much is being given to the EU in exchange for them taking control of this country away from us. That money can be used to sort out the NHS and ambo services. and have some left over for other areas. the government dont care, look at the army offices at whitehall, cost aprox 27k per m2. the home of army personnel falling apart building with 1960 fittings. as long as their ok we can rot in hell!!Tom for minister for health. ( just dont forget where you came from if you do)

  19. “what would happen if there was an ambulance strike?”Just to respond to this comment directly, just look at the NWAS strikes earlier this year. Striking is possible, and cover would be providing by the Statutory secondary Ambulance service (in most areas St. John or BRC). However, this obviously isn't being proposed. And, if it would have much effect anyway is another question..

  20. Regarding “making a profit” – I think the ambulance service is almost uniquely suited to doing this, in a very direct way.When you help someone, you should, obviously, take whatever money they think your service is worth. Withholding said service until such time as they use their ebbing strength to throw their wallet at you will, I think you'll find, make this situation a shining example of modern neoconservative capitalism in action.

    This also neatly accommodates the poor. You'll take whatever someone has, no matter how little it may be.

    Oh, and you'll also take what you can carry from their house.

    If that turns out to include their car keys, well, then that's another bonus, isn't it!

  21. For my sins I work in a PCT – Analysts are the laziest bunch of over paid staff I have ever come across. No “real” business would pay so many people, so much for so little work. And we have all been told that requests for time off without pay will be taken seriously because it will save money. The NHS needs to consider its key goals, and stop the activities that dont do anything for this, just like “real” businesses would.

  22. Hmmm..a recent post by Magwitch also had a clicky-linky for an article in The Sun, which was the second similar story that I'm aware of, too. Im not sure whether it was you that brought it to my attention or Magwitch, but both have left me rather annoyed.The particualr service with whom Im employed operates a system of choosing whether you wish to have a disturbed or undisturbed meal break. However, this is done at the start of the shift, before youve had chance to be hammered into submission by the relentless calls to non-emergency emergencies or (albeit a more unlikely senario) nine solid hours of toe-curling trauma.

    The very suggestion that any ambulance crew would rather be sat with their feet up, swilling tea and watching Jeremy sodding Kyle, than saving someones life is bordering on the ridiculous. I, personally, am very insulted by the suggestion. However, I would rather be sat with my feet up, swilling tea and watching Jeremy sodding Kyle, than running twenty miles on blue lights to find that Id been called to someone that had a scab fall off their knee during the night, and were concerned because the underlying skin was slightly more pink than it was before.

    Herein lies the true problem. If we spent less time attending the utterly pointless, and the general public who are so quick to burn us in flames actually took some responsibility for their own, non-life threatening malaise, there would be enough ambulances to enforce such EU rulings as meal-breaks, without anyone having to wait so long for an emergency response.

    Since the implementation of Agenda for Change, I have seen no increase in the number of staff, yet a reduction in the number of hours in the working week, and the usual increase in the total number of calls. With these changes, I have never worked so hard, or been so exhausted in my whole life. The number of incidents that I attend has more than doubled. To then be told Im uncaring by tabloid journalists, and those who comment upon their ramblings, is both upsetting and insulting.

    Id like to see them work a twelve hour shift without a break, then finish three hours late, because someone ploughed a lorry into an old folks home, at five minutes to their finishing time!

    Rant over. For now.

    Oh…hang on. The rant isnt over.

    See that Fireman? That one with his feet up and a second job, when he earns more than a Paramedic anyway? You dont see his kind of bad press about them, do you?

    Where are our Press Officers?

    Rant IS over.

  23. I think this is a classic case in point of what happens when you read the Daily Express / Mail.Journalists producing total rubbish written from the point of view of the ungrateful, complaining section of society who feel the world owes them.

    Combined with a government who's only real policy appears to be “react to whats in the papers without thinking” or “Tax it!”

    It's a sad state of affairs. Rest assured that the decent hard working people of the country don't agree with this cr*p and are grateful for the job you guys do.

    Keep up the good work and don't let the bast*rds grind you down.

  24. These press stories make me angry!When ambulance staff are on a break, they are not being paid – in effect they are not at work. What next? Newspapers will be complaining that ambulance workers go home between shifts, resulting in deaths that could have been avoided if they were at work 24/7???

    Now I agree it would be scandalous if a person in a typical office job were, say, to refuse to call an ambulance for an injured colleague because they are on their lunchbreak, or if the designated office first aider refused to help someone for the same reason. But there is a difference. Ambulance staff deal with emergencies all day every day as their job. If you start refusing them breaks because a life-or-death situation has arisen, they would never get breaks.

    And then the newspapers would be moaning that ambulance workers are being forced to work 12 hours straight, without breaks, causing them to get tired and make mistakes… putting lives in danger. You really can't win with the press.

  25. “Now I agree it would be scandalous if a person in a typical office job were, say,…because they are on their lunchbreak, or if the designated office first aider refused to help someone for the same reason.”I have had that, im a first aider at work and i was walking pass reception when i hear another 'first aider' say “no, get another First aider to do it, IM on lunch!!” I looked over in dismay, to be spotted my the receptionist, i left my coat, bike helmet (i was on lunch too) and went to the injury. later i saw the 'first aider' i told her that i went although on lunch myself, relpy “well you are a f**king idiot for that during lunch” im glad she was a woman or i could of been up on assault charges.

    best of all, when she got injuried, all the site first aider said they where on lunch. she did not like that.

  26. “The second way is to reduce the number of calls we get by streaming out the 'crap' or by educating people about the misuse of ambulances. This isn't simple and would take twenty years or more to implement.”Pfft, come off it. Only in the public sector could that be true.Making misuse a criminal offence and punishing offenders with anything from a verbal warning to a 25 fine to imprisonment (depending on the circumstances) plus an ad campaign on TV, radio, printed media, etc means there is no way it would take twenty years. Changing the law is the hardest part (maybe there are work arounds whereby you can still fine people without needing to change the law). An ad campaign, the facilities to take payments for fines/chase debts could be put in place within six months – easily. You make a valid point about frightening off poor service users. The obvious way around this is to make dialling 999 free whatever the incident – toe taxis included. The EMD would tell the toe taxi person to get a taxi and refuse an ambulance. (You want to avoid the scenario where the patient has an option to pay the fine *and* get an ambo because that makes the LAS *more* like a taxi service.)So, fine the piss takers and stop sending ambulances to crap jobs.[ I think the same ought to be done with GPs since we're facing a shortage of them. I really cannot see the sense in stressing about a 'supply shortage' when you're wasting so many resources and you can, quite simply, avoid doing so. ]As for some of the other issues…Re: Meal breaks: It seems to me they should just be optional. If crews want/need an uninterupted break they should just ask. Making it compulsory clearly isn't working.Re: Timing the 8 minutes: Timing from pick up to amb arrival is retarded. It tells you nothing. The interesting times are dialling 999 to pick up in EOC, pick up to gathering address details, gathering address details to sending the tasking to an amb, and tasking to arrival. Timing from EOC pick up to arrival is so retarded. So, you meet the 8 min target. Great. But if you don't, then what? Are callers bad at giving address details? (=> more work needed at automatic location systems, better training for EMDs) Are messages taking too long to get to ambs? (=> improve internal systems in EOC) Are crews taking too long to get to incidents? (=> improve standby locations, hire more staff, rethink driving regulations) You simply have no idea. Timing these things is absolutely essential. Cutting your budget because you miss them is silly.Witholding stats from the govt seems like a thoroughly good plan. That is, as long as the LAS knows all the above times. Not knowing the info is neglegent. Not telling the government is cool.. :-)Re: Staff not telling the govt to put their targets where the sun doesn't shine: I dunno why they don't sometimes.

  27. Tom,Gawd help me, but I used to be an NHS manager. I'm better now thank you but am still a big boss in a charity. I agree with much of what you say, but it seems to me that an awful lot of your concerns, apart of course from you admirable idea of putting patients first, is about resources. There are two issues here. 1) As ever the Doctors' mouths were stuffed with gold and always have been from Nye Bevan's creation of the NHS on to the last contract review. Squillions of quids have gone on their salaries (that's consultants and GP's – not JD's ) for not much product. 2) The general standard of management accountabilty and competence in the NHS is awful. When was the last time a finance manager got sacked? Now working for a charity I find myself infinitely more accountable than I ever was in the NHS and rightly so. Or wrongly so – you get my drift. Keep up the good work, I'll try and have my first heart attack on your patch. Mike

  28. I've already had a bit of a rant about this subject, but there's a few things that I've thought of since:-Hmmm…

    1. There are already some ways of filtering the calls that have been implemented, such as Emergency Care Practitioners working in Control Rooms. This has had, so far, a mixed success, and is wholly dependant on the Call Taker passing the call to the ECP, and the ECP's ability to adequately deal with the matter on the telephone;

    2. AMPDS – The terrible system that codes incoming 999 calls does not leave any scope for an experienced Dispatcher to use his or her common sense or judgement, or for an inaccurately-coded 999 call to be taken by an ECP;

    3. ORCON is an utterly irresponsible method of calculating the successes or failures of an ambulance service. The idea that response times are or greater importance than the clinical abilities of the attending ambulance crew and the clinical care given to patients is laughable, and is probably equally laughable to the lay-person too;

    4. I have issues with the idea of fining people, or the making of a criminal offence for “time wasters”. As we are always told, every persons opinion of what constitues an emergency is different. Many of the patients I see are very far from being an emergency case, but many of these patients still need to see a doctor. Sadly, the availability of GPs, especially out-of-hours, has reduced to such terrible levels that many people now use the ambulance service for advice, too. Furthermore, at many of the genuine cases which ambulance services attend, the patient has had symptoms for several hours, but “didn't want to bother” the ambulance. I hate to think of the numbers of patients suffering acute myocardial infarction that have said those very words to me. I fear that these are the very people that won't call, should the threat or fear of criminal proceedings being instigated looms over their heads;

    5. Still on the subject of criminal proceedings, we have the clinical abilities of the attending crews. More and more crews these days have low levels of clinical experience. This is not through any fault of their own but existing staff have every right to consider career progression, may suffer sickness or injury, and people regularly leave the ambulance services, etc. All of these factors require staff to be replaced. While moral remains as low as it is, staff turnover will always be a problem. So, who decides that a person is a timewaster, or should be subject to criminal proceedings?

    6. Hospital closures are a large contributing factor in the reduction of available ambulance crews and vehicles. If an ambulance has to transport a patient to a hospital twice as far away as the previously-nearest receiving unit, then it's going to take twice as long before it's available again. It's not rocket science to work out what this means in terms of response times, but it also affects patient care, too. Some patients require clinical procedures that can only ever be carried out in the clinial setting of a hospital, regardless of how good the ambulance crew is. As for the likelihood of a good outcome in the event of cardiac arrest, survival rates are low enough to begin with.* Hospital closures also often begin with a reduction in services, and these things are often not relayed to the general public. This means, in essence, that the patients that have made their own way to hospital are later transferred to an appropriate treatment centre by ambulance, causing another reduction in available ambulances.

    I'm not going to provide answers to any of these problems, but they're food for thought.

    * For the lay-person: try doing press-ups on top of a sofa for an hour, or doing twice as many as normal. Occasionally, you can stop for a few seconds, to progressively drag the sofa from a third-floor flat into the back of a van. Once in the van, continue doing press-ups until you've driven about for half an hour or so. Share this with a friend, and that's CPR, not including things such as defibrillation, intubation, IV access, drug therapy, etc!

  29. It would be nicer if the papers could look at the other side of the story.”Incident happened at location X. Y-number of ambulances have stand-by points within 8 minutes of location X. Two of these were having an unpaid break to eat and go to the loo in the middle of their 12-hour shifts. Of the others…” and then list what each of the others was doing for that 8 minutes (surely it's logged somewhere).Showing that most ambulance crews are not out saving lives but are dealing with stubbed toes, sore throats, nosebleeds, and drunks, might help matters.

  30. You know, I bought and read your book last year and I check this journal everyday. I'm not one to comment usually, but all this has really pissed me off.When my paper came through my letter box this morning and I saw the glaring, accusing headline of this story on the front page, I refused to even read the rest. Quite frankly I am sick of the tablots presenting things as they wish us to see them instead of how they really are.

    I have no idea how the hell you stick with the job that you do, its completely evident to me that it's not for the money or for an easy life, therefore it can only be for the love of it, they should print glaring headlines to that effect, along with a typical working week for you guys.

    Sheesh, I must have PMT or something, the whole thing has made me so mad that everybody I've spoken to today, I have made a point of putting them straight on what a hard job you guys have, oh and I also cancelled this particular paper, arsewipes.

    Wow, that's quite a rant for a lurker!

  31. The ambulance service doesn't need more money, or more ambulances, it needs less abuse.It's all down to education. I have no idea how you might go about it, but teach everyone some basic First Aid. Teach them how to clean a superficial wound and how to put a plaster on it; teach them how to tell the difference between a wound that will heal by itself, one that needs medical attention soonish-but-not-immediately (i.e. get the bus/a friend to take you to a minor injuries unit) and one which needs a blue light taxi ASAP. Teach them how to treat a headache and how to deal with someone who may have had a head injury; teach them what to do with a stubbed toe or painful ankle; teach them the difference between a stuffy nose and “difficulty in breathing”. Teach them how to treat a burn, and when one is considered serious enough to require medical attention. Teach them to recognise the signs of a heart attack and what to do about that; teach them how to deal with someone who's choking, and how to do CPR.

    If someone knows what to do in all of the above situations, then maybe you'll get fewer “crap” calls, and maybe, just maybe, some of the genuine calls will have a more succesful outcome thanks to prompt and effective bystander first aid.

  32. fair enough. I misread the level of anger. I quite agree- the whole madness of the NHS (and other public services for that matter) “making a profit” has gone rather into lala land. I too (like other posters) would rather be saved by someone who's well rested and likes their job, than someone de-motivated by targets and paperwork.

  33. Firstly I had the pleasure of reading this post, chez Laura which was very nice.Secondly you are spot on but I would add that the ambulance service is not the only part of the NHS that has been well and truly ****ed up by our beloved government (The one I have NEVER voted for) . We should ALL stop filing in the forms and chasing the targets and just get on wih the jobs which we know how to do perfectly well thank you very much!Solidarity is what we need and we need it soon before the dear old NHS (for which I have worked for half of its lifetime ) collapses under all the strain

  34. Less time measuring means more time to actually do the job. Service improved, job done. 'Nuff said I think.Regards

    Bill

  35. I totally agree with you tjwood, Maybe they could replace some of the tv ad's with First Aid, put ad's in Tubes/Stations showing First Aid rather than how to claim from an injury at work or make cheaper calls abroad.It's all down to stupid people who call 999 (an 'emergency' number) because they have a headache and can't be bothered to go to the shop to buy some paracetamol (I've heard that this has been done) or they sprained their ankle but call an ambulance for a lift to hospital instead of calling a taxi (which they'd have to pay money for).

    I think it'd help to have a call out charge implied for people who have dialed for an ambulance when one is not absolutely nescessary. Although the problem could arise here of where the line is drawn for what is/isn't chargable and also the ambulance would still be wasting time having to respond to the call. Maybe there is a way of putting a memo onto the line mentioning that there will be a call out charge if the service is not deemed an emergency, to catch people before being put through to an operator. I mean, if the governtment are considering charging for rubbish collection, why not charge for emergency services being abused?

  36. it is so true even from controls point of view. when we take a call from said “misuser” who when asked a question says the right answer in the right box,which in turn sends a crew hurtling across manchester at mach 10 because they have a paper cut and have had to break the crews meal and then when the real deal comes in and there are no ambulances left what do they expect us to do send the “MAGIC” ambulance to fix things

  37. I agree with both you and tjwood in the training of First Aid, and especially BLS, and this should be done from primary school onwards, much like the learning or languages…!As for the charging, I have to drag your attention to my comments (above). I really do fear that it would result in as many, if not more, deaths than ambulances being misused.

    It's always the most deserving that are the most reluctant to call 999.

    :o(

  38. Blimey, what a superb piece of writing! Now THAT is what they should be publishing in the papers, but of course they won't because it's factual and un-sensationalist. As I read somewhere before people would rather buy a paper which says “man dies because ambulance on a break” rather than “people saved because ambo crews work bloomin' hard”

  39. You get 'regulars'. Some of which it flags up on the computer that the police should be sent as the patient is abusive/violent. You then wait for the police. Track down the politicians and journalists and put their address in the computer.If they ever call an ambulance they'll have to wait for the police to arrive first as they've abused ambulance staff.

  40. I'm eagerly awaiting the day a politician's sick child needs to be taken past two A&E departments, because they no longer has paediatric services…or one has an MI, and the ambulance has to do similar because the cath-labs has been closed…Cruel, perhaps…but that'll teach them…

  41. But I wonder how many more people would die because they are on a pension, or very low income, and scared to pay for an ambulance – so ignore serious problems until it's too late? I do not like timewasters any more than the next person but to me blaming the public – even the a-holes among them – is not the solution and never will be.If we have billions to waste on illegal wars, why don't we have enough money for an ambulance service that allows for human imperfections and stupidity? Our politicians are allowed to make mistakes that cost far more lives in the long run than even the stupidest stubbed-toe callout.

    Getting the grunts – you, me, the public and EMTs – arguing over who is at fault and who needs to buck their ideas up neatly allows the government to avoid the realities of under-investment.

  42. LOL I'm thinking you are also uniquely placed to harvest organs as well, and I hear the black market in those babies is quite profitable!Call out an ambulance for a misjudged labour, or indigestion? Thank you ma'am, that'll be one kidney, several pints of blood and we'll be having that long hair to sell as extentions as well.

  43. The most effective way to handle the nonsense 'stubbed toe' calls? Make people pay for it. If you paid for the ambulance, you'd be less flippant about calling for one. NHS isn't being submerged by 'profit seeking' bureaucratic directives burning up your resources. You're dealing with a simple supply and demand issue. You price a scarce good (like your time and the ambulance itself) low and you'll find a shortage. That's why you can't finish lunch, because there is no free lunch.

  44. I love your blog, amigo. Really down to earth.I woke one night at four in the morning becuase I couldn't breathe, and it hurt like all hell had broken loose. My dad sat me up, and made me breathe for ten minutes. It hurt like nothing I have ever felt. He then casually drove to the ER himself to see what was wrong with me. It turned out I had some crazy disease that messes the lining of your lungs up, but the point is thusly; I wish an ambulance could have come and got me! I know a few paramedics, and they are all great people. When I read that article, I figured it had to be skewed somthing awful, since no decent paramedic worth his salt would stand by and let people get hurt. I really hope the situation over there gets better for you guys! I'm rooting for you on this side of the pond!!

  45. You won't lose your job. lad. You're too famous now. Another answer is what a lot of towns in the US are doing…privatize. Let them deal with that a while and they'll pay you anything you want.

  46. I'd like to see politicians educated in the correct use of ambulances – ie, to not make them the stop-gap for many other services such as mental health care, addiction treatment and shoddy GP services. Also, allowing them to be ambulances – as opposed to generators of statistics, quota-fillers and target-hounds – that might be nice.

  47. Yes it is possible. Perhaps you should write directly to;The London Ambulance service NHS Trust

    220 Waterloo Road

    London

    SE1

    There may be a restriction on how long you ride out and you will need to sign a waiver “giving your life and soul away” be aware how expensive it will be to live in central london for weeks at a time. If you have a relative or friend living in the area. State which area in your letter and it is more likely to be re-directed to the AOM in that appropriate area for action. Regards Bob

  48. Some more thoughts, some silly. Scenario- ambulance at the end of every road, crew in suspended animation. Crisis! Little Johnny at no 3 stubs toe. Ambulance crew animated, arrive within government target of 3 mins, government and public satisfied. (Ambulance crew not paid while suspended, also no meal breaks needed as not hungry when suspended.)Or, how about combining the post office with the ambulance? Perhaps it could also be used to deliver the milk and papers and there could be a counsellor on board ready to rush to the “traumatised”.

    Seriously though, the government actively encourage patients to be demanding and are undermining all aspects of NHS which have to do with vocation and caring for people. In GP land we have to chase points all the time otherwise the GP's don't get paid. Not all GPs are money grabbing but some are.

    A recent idea from on high is that patients will be given a questionnare asking when they would like their GP surgery to be open. Surprise, surprise they will say midnight or 9pm or 4am. The next step is to virtually steal money from GPs if they don't provide these services. Meanwhile more and more secondary care is being pushed on to primary care whilst they take away our health visitors , district nurses etc.

    so, come on folks, what are we going to do about it?

  49. I have a lot of sympathy for the views expressed (in numerous comments) on the Government's insistence on change (sometimes for its own sake it seems) and requiring endless statistics.A fundamental problem with recent governments might be embodied in three axioms (and I am sure you can think of others):

    1 change creates the illusion of progress

    2 it you can't count it, it's not important

    3 if you didn't write it down, it didn't happen

    If the theoreticians – Government Ministers, and Whitehall Mandarins – can move away from this mindset and listen more to the practicioners – the professionals who actually do the work – we might see better progress.

  50. Well that'd be me dead then, and I have a job. Sorry, doesn't appeal, and anyway we DO pay for ambulances – just, via our taxes, not via personal healthcare/one off payments.I know of good honest hardworking people in the States who have been saddled with up to a decade's grinding debt over a serious illness – their long-term plans destroyed, and the emotional and mental burden making each day a misery. No disrespect intended, but that system does not appeal to me or to the vast number of other people here in the UK.

  51. A well-written article which really casts the entire concept of Key Performance Indicators in the dustbin of poor management techniques, where it belongs. Don't forget that like all methods of measurement end up changing the value being measured – blindingly obvious when it comes to a subatomic particle and quanta changing their state, but what about at a macro-scale? A well-known airport (in the UK) specified that the first item of baggage from a flight must be on the carousel within 15 minutes of the flight landing.The handling agents promptly employed people whose sole job was to drive their car out to the landed aircraft, take a bag off of the plane, and rush it back to the terminal to meet the KPI requirements.

    As a result, everyone was happy with the job they were doing, only it turned out that the measurement modified the behaviour being observed.

    A friend of mine recently gave me a very interesting briefing on how ambulance services in Australia operate, based on a subscription (35/annum) or full-payment (~500 per call out) model, but with the ambulance services needing to make a profit, so they spend a substantial amount of their income on minimising the number of calls, through education programs. They go into schools and teach first aid, they go into pre-school and do accident prevention (a majorly under-recognised role of ambulance service personnel in the UK, imho), they give their users calendars which build up a trust relationship.

    Although, as I understand it, there is no direct competition (with one ambulance service per state), this does mean that the ambulance service is far less likely to be abused, and is just one thing that my tax money could be better spent on than, say, monitoring KPI achievements.

    David

  52. There is absolutely no doubt that urban crews, run ragged throughout 12-hr shifts, must have enforceable, statutory meal/rest breaks. The vehicle/crew are simply pulled off the combat line for a rest for which they are not paid anyway – so what is the practiclal/ethical dilemma therein? I don't see one.However, there is another – probably even dafter – aspect to this business, affecting rural crews.

    We exist where we do for entirely different reasons to those dictating the need for urban crews, and we'd be the first to admit that we spend a lot of time sitting. There's plenty of stress in the rural job – but it is seldom occasioned by the prospect of facing 12 hours without a break! Furthermore, many rural stations have only 1 vehicle on shift, with the next one 20+ miles away.

    There is a strong body of opinion that believes that enforcing meal breaks under such circumstances is total horse pooh. Today the phone rang.

    Despatcher: “Are you on a break?”

    Me: “Why?”

    Despatcher: “Well, I've got an emergency and you're all I've got free in (describes area of approx 400 square miles)”

    Me: “Well for (blasphemy's) sake, put the (profanity) thing on the (profanity) screen!!!”

    Despatcher: “Gosh (or similar); thank you very much.”

    As it happened, we weren't on a break. As it also happens, my permanent partner and I couldn't care a stuff about breaks anyway – nor could most of our colleagues. We are uncommitted typically for 80% of the time, so why on earth should we care? It is distance that dictates our existence, not call density.

    The job was a 65 y.o. gent with a bad cardiac history and severe chest pain; we had a run of 23 miles (That's another 8-minute response buggered!!). When we got there, he needed (and he got) the full works; and we booked off 2hrs late. So what?

    Had circumstances been different, the Despatcher could well have held that job for another 20 minutes before calling us.

    Think about that one.

  53. Hi Tom,A great post,

    I've just signed the petion on NeeNaws blog,

    hope it helps.

    Loved you book, as did my daughter.

    Just wanted to send you and all you colleagues

    my appreciation for what you do.

    Respect.

    sarah

    x

  54. They may eventually be transferred to a private hospital, but the initial treatment will still be provided by the NHS… Whoever heard of a private hospital treating life-threatening conditions…? The patient might die, and that wouldn't look good in the shiny brochure…!The very fact that they all have private healthcare providers just proves that the money going into the NHS is insufficient. Especially when you consider that it'll still be the same doctors treating them, just with Sky TV and without the waiting…!

  55. As an aside, training people – not just girls – to COOK might lead to a slightly healthier diet, and teaching basics of anatomy (like your hearts isn't in your lower tummy) and nutrition etc might also help people appreciate and respect their bodies more.A sort of user's manual to the bod, complete with troubleshooting (first aid) and so on?

    Appeals to me, I try to stay informed on account of not wanting my body to die before I'm ready to go with it!

  56. Oh yes. That one won't happen, and if it does, depressingly it'll be swept under the carpet like depleted uranium damaging innocent Iraqi babies, which is a “no go” even for the Independent (aka “we alternate between Iraq = bad, climate change = bad”)Bummer.

  57. Well said Tom, bet you any money the tabloids wouldn't take that post and serialise it!Will post an addy for an online petition in an effort to make the public educated about appropriate uses of ambulances when i findthe link tommorrow.

    Just as someone pointed out above, our Trust decided that we should only be paid for 11hrs so that other hour is ours. Don't blame us, don't blame our managers for finally looking after their staff…blame the ignorant sods who waste our valuable time.

  58. And that's fine. Your NHS doesn't appeal to most of us, either. We have health insurance here that usually covers most health problems. In the end, it's a person's own fault for not taking precautions against the possibility of expensive medical procedures.Also, my family was one of those families that ended up in debt. That's how life is sometimes. Frankly, I prefer that to having a paramedic in a /car/ respond first and then deciding whether or not to transport.

    If you have a serious health issue and decide against calling for an ambulance due to costs, you have priority issues.

  59. “If you have a serious health issue and decide against calling for an ambulance due to costs, you have priority issues.”Asking from curiosity – what happens in the US if you literally don't have the $500+ or insurance? Can you get an ambulance anyway? Is there any sort of check on whether the patient can pay first or is it a question of sending the bill after the event and getting told to whistle for it?

  60. Yep, you get an ambulance anyway and then later you get a bill. If you have insurance, they may cover all or part of the amount if it was an actual emergency.If you don't pay your part, someone starts calling you at home and telling you that you need to pay. I suppose if you are A) so broke you don't have a phone or B) homeless, that this is not a problem.

    Same deal with going to the ER. They have to treat you if you show up regardelss of if you have insurance or not. Medicare or medicade takes care of a few people, some never pay, and the rest of us take up the slack with higher costs. You can't go to jail in the us for being in debt (yet) – the worst that can happen is that your credit gets destroyed. Big deal if it's already bad (or you're homeless).

    There you go.

  61. …although for some reason it worked wonders for my dog, I only had to tap him twice before he associated the sound of rolled up newspaper with being naughty, then it was a switch to the 'disappointment' model. “He's obviously read the old training books! He sounds smart, most dogs can't make the association between the preceeding behaviour and the outcome…that's why if you are using a deterrant you have to use it at the exact second the behaviour is being displayed, otherwise it runs the risk of confusing them / making them feel threatened and they just get the idea that you are mean rather than you are trying to teach them something.

    “because with my dog it would be a tap, while with the DoH I'd need a run-up to get the right amount of force behind it…”

    Absolutely!…and it'd be tempting to say a lot more than “no” as well…

  62. Pretty bad then for me, as a self-employed person who needs good credit to rent a home. Maybe then I could also become homeless and thus receive all the “free” healthcare I needed… somehow doesn't appeal!My point that keeps being overlooked is that I already pay for any ambulances I may use – through my not inconsiderable tax bills. That this government has odd priorities with where it spends our money is the issue, not which country has the best system since I'm very sure both have their good points, and their downsides.

  63. 46 million Americans apparently don't have health insurance – that's around 3/4ths the population of the UK. And I'm guessing most aren't uninsured because they're so rich they can pay for each procedure…. Must be a bummer for those who do pay, to carry the non-payers.I think, with regards to your last sentence (which I've been trying to get my head around and address for some minutes now), it's more that faced with such huge fees, I may have tried to ignore a health problem rather than run the risk of debt, thus possibly allowing it to get beyond the point of being treatable. In 1997 that may well have killed me, but I'd rather not go into detail.

    I hope that clarifies my point, and I'm quite sure that any country trying to impose their ways on another always leads to disaster anyway, so rest assured I am not trying to say the US should adopt an NHS style system, any more than I think we should try to adopt a US style one here.

    It seems given our govt's tendency to extract stealth taxes we would end up with the worst of both worlds anyway – paying via taxes AND private insurance, and that makes sense to no-one.

  64. This sort of post is the reason that I keep reading this blog – it is excellent! I believe that the answer also lies in education. Start teaching first aid in schools – to everyone. Introduce personal health care to the curriculum rather than “citizenship” and “enterprise education.” Then run national advertising campaigns on when to call the emergency services and when not to. I think that refusing to pass on statistics is a great idea. If only schools, hospitals, emergency services could all get together and say “Enough”I will contact my MP next and send her the link to this. And ask her what she is doing about it. Could more of us do that?

    Thank you Reynolds.

  65. Although it would not be popular, charging a fee for an ambulance call will be the only way to ever reduce the unlimited demand for the service. As the ambulance staff become better and better trained, the incentive to call an ambulance rather than visit or attempt to call out a GP becomes greater. The better you are the greater will become the demand. The NHS bit the bullet on this one for prescription drugs decades ago and started charging exactly because it realised the demand for free prescriptions was unlimited.Of course the charge would not have to cover the total cost of the call but be enough to make people think plus cover the cost of admin and collection. Would exceptions be made for calls to public places and those on benefits? Probably. Would this be perfect? Of course not but the alternative is the service being rationed by availability, which is the situation we are fast heading towards. The whole “meal break” scenario and the problems of covering this is symptomatic that this form of implicit rationing is creeping in on the margins of the service.

    The person best placed to judge the necessity of an ambulance call is the caller and if the cheapest, most available health service is an ambulance compared to accessing a GP then wouldn't would any rational person call an ambulance? Im afraid introducing a fee will be the only way for the Ambulance Service to remain an emergency service and not an on-call health service.

  66. I think that part of the problem is that we are *trying* to become an on-call 24hr healthcare service rather than restrict ourselves to just emergencies.That is what the government seem to want us to become at any rate.

  67. *thinks about it*The problem there seems to be the “one size fits nobody” approach. I want to believe that someone, somewhere, in a position of authority for the NHS realises there may be differences between central London and the bleak wilds of Ruralshire, in terms of needs, demographic, achievable targets, etc.

    I fear I may be disappointed.

  68. Mr Reynolds, you speak perfect sense. From what i have seen the ambulance service is oversubscribed, with too many timewasters/drunks abusing a service that is there to save lives. In my opinion if crews do not take rest breaks, they could become fatigued and then mistakes can happen.

  69. Yes, yes! Stop handing over the figures. Perhaps the money spent on unnecessary adminstrators and statistitions could be diverted to provide more ambulances?If the Government wants statistics, let them provide one, and not out of LAS funds.

  70. It's seems the problem is not so much with the EU law or the ambulance crews, but with the management of the ambulance crews who allowed breaks to be scheduled so that there was a total lapse in coverage. That's an utter failure of the management.thanks to weight loss i am not a fatty anymore.

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