On How Targets Directly Screw Patient Care

So… What is it that makes an ambulance?

What sort of equipment do you think needs to be on a vehicle for it to be classed as an 'ambulance'.

You'd probably think that it would need a stretcher, a carry chair and some sort of medical equipment. Perhaps something to take blood sugars, blood pressures and tracings of your heart.

Maybe it would need something to deal with broken limbs, a board to strap you to if the crew thought that you had a broken neck and maybe even some drugs to treat conditions such as asthma, heart problems and allergic reactions.

You might also expect bandages.

You would, of course, be wrong.

We have had the official memo from one of our Assistant Director of Operations.

To be a working ambulance you need…

1) A vehicle which passes the legal requirement of basic roadworthiness – decent tyres, has a windscreen, has working lights and is taxed.

2) A Bag-valve-mask and a defibrillator.

3) That is all.

That is all you need to have a working ambulance – or rather an ambulance that will stop that all 'important' (and utterly bloody pointless) ORCON target.

This level of equipment means that you can perform pretty basic life-support – no drugs, no clever airway management.

If you have asthma, you will be wheezing like a wheezy thing with not a thing I can give you.

If you are having a heart attack I won't be giving you the aspirin that vastly increases your survival rate.

If you have a broken leg, I'll have no way to splint it. And I may not even have a stretcher to put you on anyway.

But I will have 'stopped the ORCON clock', and so the job will be a 'success'.

—–

And this is happening – a friend of mine was sent out on an ambulance with this level of equipment. He was concerned by this and wrote a letter to our medical director who replied that this is a good policy.

Over 50% of the time I'm sent out on a vehicle without a blood sugar kit, and without other equipment like Scissors or a Paediatric Advanced Life Support Kit.

The London Ambulance Service calls itself a 'world class service' – but I think it's a bit rich to refer to yourself as this when ambulances are being sent out with this level of kit.

But who am I to complain that I don't have the right amount of kit? After all, the people who make these decisions are paid a heck of a lot more than me, so they must be smarter.

—–

It is, as regular readers will no doubt have guessed, all because of the frankly dangerous ORCON target – dangerous because our ceaseless chasing of this clinically worthless target means that patient care is suffering.

The government has decreed that a number of targets will be dropped – the four hour A&E wait, the Police Pledge, Literacy (well… they haven't specifically said that literacy must be cut, but if you are cutting the education budget by 25% then that is the sort of thing you are going to get).

Sadly, no, tragically, it would seem that the ORCON target will remain. And so resources that could be spent on, oh I don't know, fully equipped ambulances, are instead being spent on beating that damn clock.

However I think that there are those in management who probably like this – after all they can understand how to chase this target as opposed to being capable of setting a standard of excellent patient care.

39 thoughts on “On How Targets Directly Screw Patient Care”

  1. It's not that we don't use the kit, it's the one time you get a call to a patient having a severe allergic reaction to something and you can do diddly squat about it because you don't have the right equiptment so you basically have to watch that patient suffocate in the back of your ambulance.Alieneyes- It's not about who uses the kit, indeed, if the kit ever gets used, it's about it being there when you need it to save a life. We do this job to help people and to save lives, not watch a life slip away because we dont' have the kit we need. That is not what we signed on for.

  2. It's because the Government won't stand up for themselves and say “no, this is the best way to do it and we know t is because we've talked to people who know what they're talking about and they think this is the best way forward. When you know anything about running a city-wide public service THEN you can come moan at us”

  3. Surely all it will require is a test case to go through the courts, where a court can be convinced that this practice will be detrimental to patient care.With the threat of litigation following legal precedence, ORCON would be dropped faster than a prom dress!

  4. For what good it might do, I've written to my MP with this. The Health Secretary is in the neighbouring constituency, so there's a chance it might get passed on.As you say, the new Government have cut similar things with the police. Just because they haven't cut this one *yet* doesn't mean they won't when they get to look at it; they seem to be trying to undo some of the worst of previous policies.

    I also suggested that Tom would be a good person to talk to if they wanted a view of “Front Line” patient care – hope that's OK Tom.

  5. The reason “the management” have introduced this concept of an Ambulance is because “they” have failed to put in place processes to ensure that ambulances are stocked up, checked out and ready to go at the start of a shift. So, a crew come on duty and do their Vehicle Daily Inspection (VDI) before going out. If however, a call comes in before they have finished the VDI, because the management do not want to miss the target, they say to the crew, “out you go” with the basic checks done as per the memo.Its a case of covering up a failing (the ability to ensure ambulances are kept well stocked and are roadworthy) by putting in place a process that pushes the problem, yet again, onto the poor crews who have to risk not being able to treat potentially life threatening conditions.

    On one shift, we said we could not take the ambulance out as its tax disk was out of date. We were told we would be disciplined for refusing to take a call if we did not go out. Once again, their failing (ensuring a vehicle is taxed) was covered up by trying to bully and threaten us to go out. A phone call to someone with a few more of those special cells sorted that particular problem out.

    We all have our jobs to do in the ambulance service. However, it seems to crews that the only ones that are ever really measured on thier “performance” are the actual crews themselves, and worse, the only ones who are ever taken to task over any failings are crews as well.

    I have lost count of the number of times that Paramedic Drugs Packs are not available at the start of a shift. I have never known a DSO be disciplined for not ensuring that sufficient stocks are maintained. When a DSO was challenged once, he shrugged his shoulders and said, well if you lot keep using them, what do you expect !!……

  6. I'm a volunteer for a leading First Aid charity. We don't respond to emergency calls but even our ambulances, kitted for patient transfer work, feature O2, Entonox, a stretcher, carry chair, scoop, board/collars, airway management and suction equipment, splints, etc. We even carry aspirin…

  7. Dear Tom,Bit of a missed point here. The “definition” not of an ambulance but of the minimum required to attend a call has been already discussed.

    Point of note only a defib is required to stop the clock. Hence a community responder or indeed a defib placed in a public place, plus a person trained to use it do stop the clock.

    DSO

  8. Hi TomThis seems a little misleading. I've seen this LAS memo (though I work in the sticks). Isn't the agreement that you would attend and be immediately backed up? As a dispatcher I have this argument continually. There IS sense in it, even though it's not ideal. If my mum had an SCA I would want to know that control sent the nearest ANYTHING with o2 and defib, plus the nearest crew.

    Also on ORCON, clinically pointless? Yes. Totally baseless? No. It's what the public want. The headlines are always 'ambulance took 30 mins to arrive' as opposed to anything clinical. Public get what they want even if it's not the best for them- same with bobbies on foot patrol- public love it. Totally useless if your getting a kicking two miles down the road though!

  9. If they gave you all the necessary equipment, it would slow the vehicle and cause you to potentially miss the ORCON target.

  10. Think about it – if we were to be 'immediately' backed up, then why isn't that 'backing up' ambulance being sent on it's own while the ambulance with no kit is being stocked up?In London at least, with short running times, why are we needing to send an unequipped ambulance to calls?

    It is similar to what happens when a FRU is sent to a job – they can be crying out for an ambulance, but if the call is 'covered', then ambulances can be sent to other 'uncovered' jobs.

    And yes, a large part of ORCON is public perception. But on the flip side, doesn't the public expect an ambulance to have bandages and the ability to transport them to hospital?

  11. The point is that there is a difference between what a member of the public thinks an ambulance is (bandages, drugs and an ability to transport) and what our bosses think an ambulance is (ORCON stopping machine).How do you think the public feel when an ambulance turns up to granny and her broken hip, only to stand around unable to do anything because they have no kit?

    It's just not good enough.

  12. The FAA requires all US commercial jets carrying more then 50 people to carry defibs and O2 (amongst other things).Which means that domestic flights in the US have to by law carry more advanced medical equipment then an ambulance in London (as they also carry FA kits with antihistamine, aspirin and inhalers).The CAA currently however does not require defibs to be carried on board (and I am too lazy to find the stock levels needed in kits and O2).

  13. As well as writing your MP, a way to get heard is to go to http://yourfreedom.hmg.gov.uk – and start a petition there.No. Start two.One to squish ORCON, one to set a reasonable minimal standard of what makes an ambulance.Then post the URLs here, and warn anyone that clicks on them to keep retrying until it works, because the site's seriously oversubscribed, underpowered… and apparently running on AmigaOS?Maybe mention the http://yourfreedom.hmg.gov.uk/restoring-civil-liberties/repeal-the-digital-economy-bill one, too.

  14. Well I guess the only real way to solve the FRU problem would be with… Another time target! :-p I can only imagine things are a gazillion times worse in London than they are here. I personally believe that ambulances shouldn't be used for A8 performance. It puts unacceptable pressure on crews, and they're too bloody expensive! Get in a load of first responders for that- they're motivated, the public love them, people love doing it and they're dirt cheap. Leave ambulances for backups on properly placed stations. More training time, more time to rest, hopefully less than 30 activations a day. Might not work with London traffic though…

  15. Dear DSO,Its a managers job to ensure that the LAS puts out fully equipped ambulances. They are unable to undertake this basic of tasks.

    So, they re-define what an ambulance “needs” in order to hide their inability to do this task.

    Its crazy, and everyone knows it. One day, this will all blow up in the LAS's face.

  16. Dear DSO,Its a managers job to ensure that the LAS puts out fully equipped ambulances. They are unable to undertake this basic of tasks.

    So, they re-define what an ambulance “needs” in order to hide their inability to do this task.

    Its crazy, and everyone knows it. One day, this will all blow up in the LAS's face.

  17. Dear DSO, I dont think Tom has missed the point. Yes that is the policy, but it is flawed.Firstly, As a paramedic, I could turn up with an empty ambulance to a cardiac arrest with a defib, bag and mask and my paramedic kit and be able render the appropriate treatment that is required of me, however, I would not be able to treat an asthmatic, diabetic or chest pain etc. Certainly I could transport these patients to hospital but I would be delaying their treatment, no matter how quickly I get them in. the only positive is that if they were then to arrest because of their condition I would be able to effectively treat them on route. Surely preventing this happening in the first place is preferred.

    Secondly in London we have agencies in place to ensure there is always a vehicle that is equipped, cleaned and stocked and that there is a number of spare vehicles also equipped cleaned and stocked to prevent down time. I believe this is the reason these agencies were employed by the service. They fail consistently. A week never passes where I do not have an available vehicle at the start of my shift. I am often asked by the control room do I know where the vehicle is. I have no answer and I have to explain that as I am at the beginning of my shift I wouldnt know and often have to experience their annoyance. Regularly I have to clean, stock and equip a shell of an ambulance that doesnt arrive for three hours into my shift. Im sure if I were to turn up three hours late for my shift on a regular basis then there would be a disciplinary hearing.

    As a practicing paramedic and one who is happy to work hard, and do all I can for everyone I attend during my shift, I ask only one thing, a fully equipped, ready to go ambulance at the start of my shift.

  18. I think that was Tom's point DSO. We shouldn't be concerned with “Stopping the clock” and appeasing the great god ORCON, we should be a “world class ambulance service for London”, and we will ONLY achieve that by delivering the best patient care at all times. That does not include responding to a 6D1 without any equipment to treat asthmatics, for example.Why is it so hard to update the equipment in time?

  19. If you could be immediately backed up, why don't control send that backup vehicle that actually has equipment on it?Why do we persist in trying to put in place small changes, rather than reviewing why the current procedures do not work as they are?

    I agree with the police comment though Wimbo. Single Patrolling makes little sense in terms of officer safety, but as the public wanted it, they got it. It is again though an example of trying to make small changes to create the appearance of fixing a problem, instead of assessing the fundamentals of what the operation and task is, and finding out what the ACTUAL problem is.

  20. Tom – you may be missing the point!You, as a highly trained paramedic, indeed are uncomfortable at the lack of equipment as any of us would. However, you persist in documenting the reality of the calls you attend – which require a social worker and or basic life skills, not a paramedic. Politically, the statistical failure rate of not rescuing a genuine case is outweighed by the dross vs expenditure that you so lovingly document!

  21. What is an ambulance?”an ambulance, being a vehicle (other than an invalid carriage) which is constructed or adapted for the purposes of conveying sick, injured or disabled persons and which is used for such purposes”

    So, a vehicle with seats. LAS are exceeding legal minimums for an ambulance! Be thankful for the miniscule amount of kit you're graced with…

  22. Quite right it is the service's responsibility to provide the appropriately furnished vehicle. Ever wonder where all that stuff goes? Me too.This could easily drop down into a blame game, me pointing out that I haven't carlessly missplaced a BM kit in a very long time or pointing out that there are several aspect of your (EMT/Para's) jobs and responsibilities that conveniently slip from your minds when we're holding people to account.

    I still spend as much time as possible trying to provide these essentials and believe it or not, stilll care immensly when I'm unable to provide them.

    My point is two fold; the policy is created to define what you can reasonably be asked to render aid with and what can't. It protects staff from malicious critism and protects patients as well. Equally the policy has nothing what-so-ever to do with ORCON. I mean I get it, no one likes it but guess what, its the thing that matters most to patients and I do think we should all care a little bit about that.

    DSO

  23. Well put.This is a blindingly simple issue.

    The “what minimum kit is required” procedure is designed to ensure a crew can be sent on a job as soon after shift start as possible. At the purest level, I have no problem with that. If a call comes in, we should respond to it as quick as we can.

    However, the reason the LAS “need” the procedure is because they are unable to provide fully functional and kitted ambulances for crews coming on shift.

    We do not do VDI's because we would rather walk up and down the garage getting kit and making sure the ambulance is ready to go than actually attend calls, we do it because we have to, as the vehicles are a mess !! and we take our responsibilities as health care professionals seriously.

    The sub text to this is this is that the crews are using the “we are doing a VDI” line as an excuse for not going out !! – this thinking is out of date, insulting and frankly a bit dumb. In addition, I know kit goes missing, but again, the sub text is that we are stealing or losing it and we must therefore be punished by not having it replaced. Same comments apply to this assertion as to the VDI issue.

    If everyone did the job they were paid for, these issues would go away. A managers role is to support crews, not constantly treat them as lazy buggers who must be viewed with suspicion at all times.

    Interestingly, I have never known a hard working Paramedic to have aspirations to be a manager, they want to stay clinical. So, where are the managers drawn from, maybe not the cream of the crop ? – discuss.

  24. If we just fulfilled the legal minimum, then we wouldn't be able to provide any treatment. The definition from the Road Traffic Act does not describe the ROLE of an ambulance, only the legal definition for that purpose. The definition <> the role.Surely we pay the company that does make ready for us, to prepare the vehicles. I hope to god that we aren't paying them for this wholly unreliable service.

  25. Trust me, I said that entirely as a cynic. The RTLR is not a clinical policy!Given the amounts of cutbacks the nation is facing, it's almost plausible that we will end up with taxis with lights and no kit. At all.

  26. It's rather easy to suggest that crews are stealing equipment and not doing our job while being anonymous.I own my words and my opinions – that's why I'm not anonymous.

    My point is that the policy is, in my – and probably most people's opinion wrong. That a BVM and Defib are worthless for most of the jobs we go to.

    After all if we are to chase ORCON because that is what the patients want (and if they want us all to sing showtunes, should we do that as well?), don't you think that they'd want an ambulance to have some kit on it?

  27. If everyone did the job they were paid for, these issues would go away. A managers role is to support crews, not constantly treat them as lazy buggers who must be viewed with suspicion at all timesTo be fair, our managers at DSO level are supportive. They themselves are just as frustrated as we are, as are most control room staff that have to speak to us on the phones. I believe the problem is higher than that. We employ outside agencies and managers that have no idea how the inner workings of an ambulance service function. When you hear from your immediate line manager that there is 95% crew availability and yet there is only 87% vehicle availability, then there must be something seriously wrong. The Duty officers themselves are only given figures and do not actually know where the vehicles physically are.

    The solution is really quite simple. Bring back the control of crew staff and vehicle management to local level. If each complex had designated vehicles to designated call signs and had available spares then this problem would disappear overnight. Each station would be responsible for its own ambulances. Crews would ensure equipment would be replaced as and when required. If an ambulance must go into workshops then move all the equipment from one to a shell and move it all back when it returns. This shouldnt take more than an hour, as opposed to the three hours it can take i.e. finding a shell and scrounging the gear to put onboard. Also this would save an enormous amount of cost and save the service a fortune, which could be invested back into the service.

  28. Lockwood, your definition of an ambulance that you post appears to be directly from a dictionary. However it is not as black and white as that. As an ambulance service, there is a great expectation of us. The public perception of us is that which they see in the media on programmes such as casualty and Holby, and in documentaries where only the more serious cases are shown. I have often been called doctor many times and there is a belief that we can administer over the counter drugs such as paracetamol and anti-biotics. Many a time Ive been asked if I can stitch a wound at an address. I explain that I cannot do these things, however I have also had to apologise on many an occasion for not being able to do the things I can do because of a lack of equipment. If this was an occasional event then I would not feel as frustrated as I do, however this can happen on a daily basis, which quite frankly is wrong.

  29. Alieneyes, what is a genuine case and what is required to treat a genuine case? Well sometimes we need the tools we are blessed with, a shoulder to cry on, a kind word, a sympathetic ear, and sometimes we need a bandage or a splint or a drug. Sometimes its all of the above. To the person who has called us, in their mind, its a genuine case. Unfortunately, when we start our shift, we are not going to know what we need for the next twelve hours, unless we develop clairvoyance, and as yet I havent witnessed that. Hence why an ambulance should be equipped to the fullest it can be, so that when the emergency does come along where we need more than our social skills then we are ready to deal with it to the best of our ability.

  30. I know this comment may have little relevance to the topic on this post, but I just wanted to say that I finished your book today and really enjoyed it. True, it was published a while ago…but still….A friend of mine is looking to join up to become an EMT, so I'll definitely be sharing it with him. Thanks for all the work you put in every night, you're doing a fantastic job.

    So, yeah, thanks again for “Blood, Sweat and Tea” it has been a wonderful insight into the work you guys do.

  31. So its back to the good/ bad old days.So when i joined in 1964 made sure the horse had its oats! the stretcher was onboard, found a blanket and off we jolly well went. Scoop and run, no delays back on the run nothing to do! apart from wash your hands after the mourtury! You see its the wheel it goes around its called the new thinking. So i ask my self, why did i go on strike for better training, better equipment, better ambulances. I shouldnt have bothered. But having meet several of your so called Manergers !!! With gold braid big badges, for doing nothing, they have not even been on the road and have never touched a patient, their ans is ' im here for bronze/siver command only i dont do patients ' whats that all about and how many times do they get used for that role apart from being at football grounds during the season?? I do hope that the LAS can get its status back as the leading Ambulance service in the world.

  32. Road Traffic Act, Contrruction and Usean ambulance, that is to say, a motor vehicle which is constructed or adapted, and primarily used, for the carriage of persons to a place where they will receive, or from a place where they have received, medical or dental treatment, and which, by reason of design, marking or equipment is readily identifiable as a vehicle so constructed or adapted

    No mention of Equipment or Qualification!

  33. Plumber- a person who installs and repairs piping, fixtures, appliances, and appurtenances in connection with the water supply, drainage systems, etc., both in and out of buildings.No mention of a wrench in this definition but Im sure you would hope a plumber has one when he comes to repair a pipe.

    Carpenter- a person who builds or repairs wooden structures, as houses, scaffolds, or shelving.

    Saw? Or will the carpenter crack the wood over his knee?

    I can go on but the point is anyone can look up and quote a definition but in reality if either one of these skilled, train professionals turned up to your door then you would expect that person to be equipped with the right tools.

  34. I can't believe I am doing this but:I think the question should be what is an Ambulance service?We are funded by the PCT's (while they still exist) to a finite amount. The Pct's are target driven and fine us if we fail to meet said targets.Year on year we get more calls, receiving more than 1000,000 last year and costs are increasing. Fuel has gone up over 20% in the last year and god knows what has happened to the price of medical supplies. Even if the costs remain the same with the increases in demand the costs grow at an unsubstantial level.Why do people call the ambulance service and what do they expect from us?Most people phone the ambulance service because they want medical help. Unfortunately what they get is a set of questions defined by a computer programme called AMPDS which is unable to distinguish between a serious emergency or someone who is lonely.Before I joined, I like most people believed that the control room was staffed by people with a competent level of medical knowledge, who would define the appropriate medical response. Now I realise that all you get is a human reading questions for a computer.Are we simply a glorified taxi with some first aid thrown in? If we are we are not paid a bad wage. Or are we professional health workers skilled in, social work, maternity, cardio-vascular, repository, and so on. In which case we are under paid and under trained.As long as the pay masters are driven by ridiculous targets and we use software to make decisions about appropriate response we are doomed to continue on our downward spiral.

  35. The policy actually goes against what has been prescribed by the HPC in a hearing as to the minimum equipment necessary for a paramedic, they are:a stethoscope to determine the patients respiratory and cardiac condition, as well as for intubation and determining the level of chest injury;

    a blood pressure machine to establish the patients cardiac condition in all circumstances, especially for traumatic or masked injuries;

    suction equipment for clearing airway mucus obstruction;

    a laryngoscope for intubation;

    intravenous fluids and cannulae;

    resuscitation drugs;

    analgesic drugs.

    see the article here: http://www.hpc-uk.org/complaints/hearings/index.asp?id=468&showAll=1

    Does that mean as a paramedic, I can state I cannot attend a call without the above, using the case as reference?

  36. “It's what the public want”. No, we don't. It's what the tabloid writers thinks we want. It's what vote-grubbing MP's think we want.What we actually want is a vehicle fit for purpose manned by crew in a fit state to deliver it. If I have a broken leg I couldn't give a flyer whether the ambulance has O2 and a defib. If it doesn't have splints, nox and some way of getting me in the van without having to walk then it's not fit for purpose and I will bloody well complain.

  37. problem is known , shortages of needed gear.any good organisation would do the following like an airline, clean out, refuel, stock up, ready for dispatch.

    It would be done if the reward or punishment is in place.

    It is called logistics.

    Sounds like LAS is like an infantry regiment, send the lads on patrol without a firing pin in their weapon, might need weapon if there is a serious fire fight.

  38. So to avoid yourself getting stricken off the HPC, best to skill yourself as a 3 or a 4 at the start of shift if you're unable to stock up. And then change to a hotel when you can get the right equipment.

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