Somehow on my 'week off' I'm busier than I would be if I were just going to work. How am I ever going to get my full Spellfire set or my next six million ISK?
(OK, nerd episode over).
I've been spurred into writing this post for two reasons – the first is this post of mine and the associated comments, the second is this article in the Financial Times. Two quick notes on the article, if the government want to employ a blog expert I can be had for a salary of, oh lets say £25,000+. Also if they want to invite me to talk to them, I'm more than happy to spill my brains the general direction of anyone in government.
To recap – the main target that the government has set ambulance services around the country is that of ORCON. This, at it's simplest, states that we should reach our high priority calls in under eight minutes and our medium priority calls in under fourteen minutes.
The problem that I have with this is twofold. Firstly, in a supposed 'evidence-based' NHS there is little clinical reason for the eight minutes as opposed to four minutes. Secondly, and much more importantly in my opinion it directly impacts on patient care.
In order to meet the eight minute target ambulance services are removing double-crewed ambulances from the road in order to increase the number of Fast Response Units (FRUs). The reasoning is that if an FRU is on scene then the 'clock stops' and the job is a success. It's not a success for the FRU if they are stuck on scene with a stabbing, unresponsive asthmatics or with a child with meningitis.
People who are seriously sick need to be in hospital, not having a solo responder holding their hand while praying in desperation for an ambulance.
Ambulance folk can do a lot to stabilise a patient, but as a trainer of mine wisely says, “the place for a sick patient isn't the back of an ambulance”. Nor is it in their own home waiting for an ambulance to turn up.
So, what are we to do? We need to check on the performance of NHS trusts, that much is certain.
My solution is to have more targets.
But targets which will have an impact on patient care.
Lets have a target where we improve the number of heart attacks that we diagnose in the home and transfer to the 'gold standard' treatment centre. I think we are at 95-97% on that at the moment. How about improving the call to treatment time.
Lets have another target where we diagnose strokes (or 'brain attacks' in the jargon of today) and transport them to a specialist centre. Of course we might need a few more places to become specialist centres first, but isn't the NHS a 'joined up' organisation?
Lets have a target where we try to reduce the number of patients with asthma who need admitting to hospital. Better, lets reduce the number of people who need to stay in ITU because of asthma. Of course it isn't the sole job of the ambulance service to do this, but our targets should inform other aspects of the NHS, just as theirs affects ours.
How about improving the measurement and treatment of pain – its something that we aren't too good at, given that in most cases our choice of pain relief is restricted to entonox or morphine. We carry aspirin, but that is for heart attack treatment, not the treatment of minor pain. We also have paracetamol for children. How about nasal diamorphine? Improving the measurement and treatment of pain will directly improve patient's experiences.
How about improving cardiac arrest survival rates. We've managed to improve this greatly over the past few years and I'll be talking about this in a later post. Unfortunately the government doesn't 'reward' us due to our improvements in this area, perhaps they should.
Time until a patient is reached is important in some cases, so we'll keep a target for reaching patients, but lets change it to only having the clock stop when a proper double-crewed ambulance arrives on scene. The other targets (like cardiac arrest survival) will be met by FRUs getting there quickly, but this will mean that there is less chance of FRUs being manned at the expense of proper ambulances.
How about a target of increasing the amount of paramedic cover in an area. Or how about a target of improving the training of people on the road? Better trained staff means better care for patients.
Maybe a target to increase the number of ambulances on the road. Even better would be a target to have a certain amount of spare ambulances. Ambulances that are waiting for a call from a patient rather than the other way around. We should have a slight excess capacity of ambulances at all times, not have people waiting for ambulances to finish with one patient before they can be attended to.
Finally, how about a 'staff satisfaction' target – a happy workforce is a more effective workforce.
Some of these targets are more important than others and by giving individual targets a separate weighting we could come up with a total 'score' that will show improvement, but can also be broken down to show where further improvement can be made. For example the number of people who get diagnosed and treated at a specialist centre for a stroke could be worth ten times as much as the number of people who get painkillers for their broken arm.
We could even keep the ORCON target, but give it a more reasonable weighting of importance.
This system would have the advantage of being better based on current evidence and would highlight areas where changes can have an immediate effect on patient care and outcome.
There is a reason why I get a warm and fuzzy feeling when I diagnose and take to a specialist centre someone having a heart attack. It's because I've done something that will have an effect on the patients well-being. It's a feeling that I don't get when I reach somewhere in under eight minutes or meet an FRU who has been on scene for forty minutes.
Right – how do I get to be Minister In Charge of Sensible Ideas for Ambulances?
I've fiddled around a bit with this blog in an attempt to resolve some of the issues some people have had with getting a black screen when accessing the site. Let me know if it works out.