Here we go…

Ambulance service gets £38 for every patient they don't take to hospital

Patients' groups expressed horror at the “sick experiment” in which NHS managers have agreed to pay £38 for every casualty that ambulance staff “keep out of Accident and Emergency” (A&E) departments after a 999 call has been made. The tactic is part of an attempt to manage increasing demand for emergency care amid failings in the GP out-of-hours system.

Documents seen by The Sunday Telegraph disclose that staff at Britain's largest ambulance service have been encouraged to maximise the organisation's income, by securing payments for diverting patients to telephone helplines. The bonuses are among dozens of schemes being tried out by ambulance trusts across the country as they attempt to improve their emergency response times and help A&E departments meet controversial targets to treat all patients within four hours of arrival. Another plan uncovered would see thousands of 999 calls currently classed as urgent downgraded so that callers receive telephone advice instead of an ambulance response.

I suspect that, once again the journalist writing this has no idea on the sorts of pressures any ambulance service is dealing with.

Our own figures show that only 10% of calls are 'life-threatening', (Taking healthcare to the patient: Transforming NHS ambulance services p8 3.4).

That is why our calltakers prioritise calls by using a computer system. We simply do not have enough ambulances to deal with the 4,000-5,000 calls we get per day.

80% of the calls to us do not require hospital treatment. Eight out of ten calls to us are for things like coughs and colds, vomiting once in a day, hangovers, headaches, period pains, cut fingers, sprained ankles, feeling hot, feeling cold and of course the plethora of 'drunk and asleep in the street'.

Now, I'm not saying that the process is perfect – far from it, there are plenty of failings of which I've written about in the past. Grannies with broken femurs are a lower priority than a drunk asleep in the street – and the main claim to fame about the computer triage system that we use is that 'it has never been successfully sued in America', and that is, sadly, a large part of the problem.

(That and the calltakers are not trained, or allowed, to vary from the script the computer gives them to read).

In the past two shifts I have been sent on numerous 'blue light' calls to drunks asleep in the street ('unconscious/not alert'), some people with colds ('difficulty in breathing'), Can't sleep ('Not alert'), Drank alcohol ('Overdose – not alert') and Fallen – bruise on thumb ('Fall – not alert'). In the last two shifts I can't think of one patient that actually required my attendance, or hospital treatment. Needless to say all the 'not alert' people were very much alert when I walked into the room and had to try and pick my patient out of a family group of the twelve people crowding into the living room.

So, why did I take them to hospital? It's because I'm not trained to leave people at home and I know that I won't get any support should that person die. I'm far from the only ambulance person with this point of view.

So, the people who commission ambulance services are looking to save the money that is currently spent on treating these non-emergency cases in hospitals. I'm not against this, after all it's my tax money that goes towards treating these non-emergency calls, and A&E treatment is expensive. It's why the government is intent on shutting down as many A&E departments as it thinks it can get away with.

So the PCTs have taken the decision that, rather than spend £100-200 per A&E hospital visit, it would be cheaper to reward the ambulance service they commission with £38 if we can either leave such cases at home, or direct them to a better place to deal with their 'illness'.

It seems sensible when 80% of our calls don't need emergency hospital treatment.

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Now, I'm going to take a quick break to admit that this isn't ideal. The infrastructure for people with sub-acute chronic conditions to be treated at home isn't there at the moment. That is, for example, the ability to be treating people with long term heart failure or emphysema at home is not, in my opinion, up to scratch.

In this blog post I'm talking purely about 'emergency' cases – the coughs and colds brigade as it were.

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With road staff unwilling to leave people at home in all but the most minor cases due to lack of support/training and a general culture of 'I won't lose my job or get sued if I take someone to hospital' it fell to Control to do a large part of the triage.

And so it was the 'Clinical Telephone Advice' desk came into being.

This is a desk with specially trained road staff who, when passed a call that is a low priority (in other words it has been through the normal computer triage system and therefore we aren't going to get sued), will ring back the patient and will talk to them and use some clinical judgement as to the best course of action for that patient.

So, for example, Mr. 'I've had a runny nose for three days, I can't get a GP appointment please send me a wahmbulance because I've run out of tissues' (and yes, I do get sent to those calls) will be triaged as not having chest pain, difficulty in breathing or any other priority symptom, and so the CTA desk will phone him back, determine that he has a cold and will advise him to suck it up and act like a man for a change.

(OK, OK, they'll probably advise he phones NHS direct or a trip to the pharmacist for some over the counter meds, but you get my drift).

Meanwhile, on the road, I'll have been sent a mobile phone mast to start driving towards (in case it turns into a 'Cat A' call) , then get sent the address I'm actually needed at, then get cancelled as the call goes to the CTA desk.

If you ever see an ambulance doing perpetual U-turns in the street, this is the reason why.

By saving the NHS £400 by not sending an ambulance who then cart him off to an A&E department, the ambulance service will receive £38 to spend on, I don't know, blankets or something.

This all makes sense, right?

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It all comes down to the question of, how much taxes would you like to pay for what degree of service?

If you want an ambulance on every street, well, that's £40,000+ for the ambulance, plus a couple of thousand for the kit inside it, £26,000 for me to sit in it for 37.5 hours a week, multiply that wage by at least six for 24 hour coverage, add in money for fuel, insurance, training of staff, the wages of those to take your phone call, etc, etc, etc…

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Moving on to the 'Another plan uncovered would see thousands of 999 calls currently classed as urgent downgraded so that callers receive telephone advice instead of an ambulance response.'

Yes.

Hell yes.

We massively over-prioritise our calls. It's why drunks in the street get a priority just short of 'dad's stopped breathing, help us please!'. All calls that we get from the police – often 'person has small cut / person needs to be checked out / person 'in shock') are automatically 'amber calls'. That's a blue light response every time.

Small cut to the head, that's a Red call as it is 'bleeding to potentially dangerous area'.

Period pain? Amber response please as it is 'Serious bleeding'.

Crying because you are upset? – Red call as you obviously have 'difficulty in breathing'.

Twenty year old with a pain in his chest from coughing too much – Red call 'Chest pain'.

Blocked nose? – Red call as you have 'difficulty in breathing'.

None if these need an ambulance, but because of the triage system that is forced upon us we have no choice.

(Meanwhile granny with 'broken leg, after a fall' is a Green call – we'll get to you when we have finished dealing with all of the above… or if one of our sensible allocators is working and upgrades the call.)

We need, as a priority, to juggle the priorities that we give calls – based on the evidence that we have collected from 4,000+ calls a day over a number of years, otherwise we just aren't able to cope with the influx of 'can't get a GP' calls.

In fact recently, Peter Bradley, our CEO chaired a meeting that proposed this – and he still got turned down.

(The government seems to adore ignoring evidence and just going it's own way – so I chose to ignore the bullshit they tell me.)

So downgrading 'puncture wound, peripheral artery' seems reasonable to me – because that, right there, is your 'I cut my finger on a lid of a cat food tin', it's not someone getting stabbed and dying in the street.

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Needless to say I don't get to see any of these £38 'bonuses', and that is almost certainly for the better, otherwise road staff would take more risks at leaving patient's at home.

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The problem simply boils down to this – like it says on the side of the ambulance we are an 'Accident and emergency' service, we should not be a replacement for GPs, we should not be used because someone can't be bothered to wait for a GP appointment, we should not be called at 1am in the morning because someone has had a 'high blood pressure for the last week'.

But people will use us like that because they want 'things' to be 'sorted out immediately with no waiting'.

Our ' core business' is A&E work, and yet we are being forced to be a medical everyman, without the funding, the infrastructure and the training – and a large part of this is based around the government not understanding that because someone has an apparently minor illness like a headache, a minimally trained ambulance worker can rule out the sorts of things that doctors train for eight years to rule out. Am I a neurologist? Can I tell the difference between a migraine, meningitis or a brain tumour?

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And tomorrow I'll tell you why our funding has been cut by £1.6 million.

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As I don't work up in Control, I'd be exceptionally happy to have any comments from Control room staff on this story – for one, I can't see how anything that is a 'collapse with difficulty in breathing' could end up going to the CTA desk as stated in that story.