How to make our ambulance service the best in the world

The ambulance service in the UK is one of the best in the world, unfortunately it has been taken for granted.

The ambulance service in the UK is one of the best in the world, unfortunately it has been taken for granted

The Labour Party is right to highlight the problem of the increased use of private companies in the Ambulance Service. They cost taxpayers millions each year.

The service they provide lacks the professionalism of the NHS service, their ambulances are poorly equipped and many of their staff are inadequately trained.

But the use of private ambulances is a symptom of deeper underlying problems that need to be addressed.

In a society that is under ever increasing stress and an NHS under severe pressure, the ambulance service is picking up the pieces. Ambulance crews daily attend patients suffering from stress related mental health problems, anxiety, and alcohol related problems that are more in keeping with community care.

The stresses of the job mean that staff retention is becoming a significant problem and an escalating cost. Experienced staff are being replaced by the inexperienced, with time and costs of training needlessly wasted.

The service has an ever increasing call volume and in some areas it is now unmanageable. Ambulance Trusts have wasted millions trying to keep up with the rising demand, but they have all failed. They lack the means to regulate use of the service, and it is now in crisis and people are dying unnecessarily.

The problem is not simply about more money.

The number of individuals, businesses and institutions who call out ambulances for trivial or inappropriate reasons is placing enormous pressure on the service. The service is free and too many people misuse it without having to be responsible for wasting its time.

The media focuses on alcohol related problems and people wanting their television channel changed. But these are a small number compared to those calling for coughs, colds, back ache, or simply for a lift to hospital.

Care and nursing homes call ambulances on a daily basis for their patients or residents for often minor problems. Their staff tend to be under paid, and under qualified, and so unwilling to deal with the problem. The private companies who run these homes take no responsibility for this failing and simply transfer their own costs onto the public purse.

Similarly, business and institutions regularly call ambulances for minor illness or injury that happen on their premises. This is often just to ‘check someone over’. Adventure sports businesses can do this daily or multiple times per week for patients that have injured themselves in sporting activity.

These are private companies that are using a free service to cover themselves against insurance claims or litigation.

Repeat callers also include individuals. Some will call hundreds of times a year, and each can cost thousands of pounds and hundreds of hours of ambulance and emergency department time.

Increasingly, sheltered accommodation for older people is losing its permanent live-in wardens. When a resident pulls their care line, there is nobody to check on them and so the ambulance service will often be called.

GPs can call ambulances for patients that have attended their practice or who they have attended at home. These patients may need further assessment, treatment , or admission to hospital.

Many do not have life threatening problems and the ambulance simply acts as a taxi, providing no care in the process. However all doctors calls in this instance are coded R2, one the highest categories for potentially life threatening problems, and which requires the ambulance service to respond to it in eight minutes.

111 is a massive burden and daily refers very large numbers of calls to the ambulance service that are inappropriate. Often run by private companies, the 111 service does not have to face the consequences in terms of cost or of overloading an ambulance service already under intense pressure.

The ambulance service exists in a complex system of demand it has no control over. It needs reform to reduce demand.

The logical first step in dealing with the escalating call volume is to scrap AMPDS, the system the ambulance service uses to screen and triage its calls. Control centres that determine call volume are manned by minimally trained staff following scripted guidelines and unable to make medical judgments.

It is a system that is designed to deal with life threatening calls, and genuine emergencies, and it is litigation proof. However it cannot deal with the vast majority of the issues patients call with. AMPDS is susceptible to over-categorising calls if the caller interprets the scripted question wrongly.

The script needs to be rewritten and the triaging and priority system needs to be front loaded with fully trained health care professionals able to use their clinical judgment and expertise.

This means investing in trained staff capable of making educated judgments. This will reduce the number of call outs, and reduce the high costs of the current dysfunctional system. It will mean savings over the medium to long-term.

The current response time targets of eight and 19 minutes should be scrapped. There is no evidence that these times improve patient outcomes and they are a hindrance to the effective operation of the ambulance service.

Reducing the huge call volume is the first step to modernising the ambulance service.

Investing in GP services will be a big help, but we need to recruit more GPs and we need a service that is available 24 hours a day all year round. The ambulance service should be able to contact people who have misused or incorrectly used the service, in order to provide advice and guidance.

And we need to think about a system of sanctions for those who misuse the service: individuals expecting a lift to hospital, or who are simply drunk; businesses covering their insurance; and care homes that lack the necessary expertise and pass on their costs to the tax payer.

To stop a large number of 111 calls inappropriately allocating the wrong priority, 111 should not be allowed to categorise the calls they pass to the ambulance service. Instead the caller and details of the call should be transferred to the ambulance service to prioritise through their system.
Huge savings can be made by changing people’s behavior.

There needs to be a national campaign explaining what ambulances are for and to make calling an ambulance for trivial reasons socially unacceptable. During the recent industrial action the ambulance service very publicly asked the public not to call an ambulance unless it was a real emergency. This needs to be an enduring campaign.

All people coming into this country to work or settle should receive basic information about healthcare including the appropriate use of the ambulance service. We need community education to prevent escalating demand. Paramedics could be assigned to worst offending local communities to work in a joined up way with other agencies on preventative health care and health related issues.

With a smaller call volume we can create a smaller ambulance service with highly trained staff.

In the last 20 years paramedic practice has been transformed into a new health profession which requires its own career progression and structure, and vocational education. Our College of Paramedics needs to become the Royal College of Paramedics. Ambulance Trusts should provide courses, learning, secondment opportunities, auditing and observation days to keep staff highly trained and up-to-date in terms of skills and knowledge.

We need Emergency Care Practitioner and Critical Care Paramedic schemes throughout the country to create highly trained professionals to deal with some of the most challenging pre-hospital patients. These schemes have been shown to be very effective and cost saving. They can be paid for by savings made by the reduction in call volume.

Recent innovations in paramedic practice and the development of pre-hospital health professional roles offer a way forward toward new approaches to critical care and longer term prevention of escalating costs.

The ambulance service in the UK is one of the best in the world, unfortunately it has been taken for granted. But by reforming it we can make this country the world leader in pre-hospital care.

This piece was written by a paramedic who would like to remain anonymous

29 Responses to “How to make our ambulance service the best in the world”

  1. Paul Chapman

    Very well written and thought out with bona fide points and argument. Kind regards Paul.

  2. Winchie

    Despite the political allusion at the outset, (The Labour Party are saying these things now, but ambulance staff have been saying them for several years – NHS Direct, the preceding organisation to 111 was always known amongst crews as “NHS redirect”) I’m sure this article will ring true amongst front-line ambulance crews and that its main tenets will engender very little disagreement. Unfortunately, several of the factors causing the over-pressure on the Ambulance Service are only the gift of Government to change. Until the facile 8 & 19 minute targets, budgetary constraints and unrealistic public expectation are addressed on a National scale, satisfactory resolution of the current (very real) crisis in ambulance provision will simply get further away from us. On the plus side, the ongoing professionalisation of the Paramedic profession, and the higher education opportunities this professionalisation process brings with it, is most welcome and long overdue. Unfortunately, the lack of a coherent, graded and appropriately salaried career structure is still leading to high staff outflow rates. Highly skilled and capable clinicians are moving to better structured, better paid and less stressful roles elsewhere in the workspace, thereby further denuding the NHS Ambulance Trusts of expertise they can ill afford to lose and leading to further strain on those that remain. The role our Ambulance crews perform is a challenging one and their professionalism is second to none, but they are carrying it out with a rope (woven from those strands mentioned above) tying one hand behind their back.

  3. Disgruntled Para

    I do think the first question 111 should ask is “Do you think the patient actually requires an ambulance”?

  4. paul

    The arrogant subjective view of a paramedic who presumes to know what is a valid call out
    And what is not, is really quite offensive.
    The use of the old standard phrase “repeat callerfrequent flyer” says more about the
    Attitude of this paramedic; and don’t get me started on the racist allusions in this piece.
    I’m not surprised he wants to remain anonymous. I think its time he considered changing
    Jobs. I hear Tescos are recruiting, although I believe they prefer to recruit open minded individuals.

  5. Alan

    Are you for real? Have you just posted your comment to be controversial? There is no arrogance to the article whatsoever. He is speaking from experience and no doubt frequently attends call outs that could be dealt with through more appropriate channels that are more beneficial to the patient. This would then would help avoid unnecessary delays for those that really do need an ambulance in an emergency situation. The paramedic does not have an attitude, there are dedicated specialist paramedics that are part of frequent caller teams trying to address the needs of patients that call for an ambulance alot. You may or may not be surprised to hear that this includes a significant number of people that call up to 20 times a month (or even daily) for trivial complaints. As for racism, you are just distorting his article. Ambulances frequently get called to immigrant communities who did not readily have access to such good healthcare and as a result are not experienced in the best way to access the most appropriate type of healthcare in the UK. Therefore wanting to provide these communities with information to empower them to access the right kind of healthcare is in no way racist. The ambulance service is stretched to its limit and this article raises important issues highlighting this. Paramedics accross the country are close to burn out and many probably are considering applying for jobs at somewheer like tesco. (and yes, I am a Paramedic)

  6. Jordaniel Ridgway

    I have been in an ambulance as a patient, once in my life. I have had an ambulance called to me at work once. The one thing missing from the article is the point that those who do call upon the assistance of Ambulance/Paramedic Services are not trained to assess whether or not a situation is life threatening. That is why they call an ambulance, because those that come with the ambulance ARE trained.

    My employers called an ambulance to have me checked over after a vehicle in the yard I work collided with mine. First aiders do not have the experiencer qualifications of paramedics and are usually volunteers as first responders at commercial premises. To infer an ambulance is called to parry the chances of litigation is unfair at the best. The ambulance was called for my well being by concerned colleagues. Paramedics do a wonderful job and are highly trained, but to suggest they are being used as taxi-drivers is obnoxious. Thankfully after assessment by Paramedics on site, I did not require a “taxi”, just a visit to my GP!

    Yes there are changes needed, improvements are always welcome. Because this service is being cut back (more due to financial pressures), the pressures upon it will continue to rise and the staff will continue to become disillusioned.

  7. AliC

    Although well intended, here speaks someone who has absolutely no idea of how the call out system works and how it tries to meet the demand. Clearly has no idea of the purpose of Pathways and resents needing to go to someones aid when in distress for something they may not consider serious themselves. Well I shall say “Don’t Knock it until you have tried it”. This is not as a user but as a Call Taker or Clinician. I would encourage all Ambulance staff to spend time in the 111 centres and learn Pathways. The perception is that calls have increased due to 111. A Paramedic crew could respond to 10-15 calls in a 12 hour shift, compared to 100-150 calls by a call taker in the 111 centre. Approx. 5% of those calls will need passing to the Ambulance service. The call taker acts on information given in response to questions. That information can change when the Emergency crew are at the scene. In my 12 hour shift as 111 Clinical Supervisor for every ambulance call I pass across I save at least 2. It is not perfect yet but if the Pathways is used consistently by all services it is a safe system. In my experience, The high demand on the emergency services is driven by the apparent inability of the general public to care for themselves and their families when suffering minor illnesses and ailments and inability to access their GP’s. There needs to be better education for the general public and easier access to services. Some Ambulance Service staff need to stop knocking the system and start more pro-active education to the general public. ‘Think On!’ AC; NHS; IHCD Paramedic; 30 years experience.

  8. Private paramedic

    Firstly privates cost nhs millions? Get your facts right we are actually cheaper than trust crews in the way that the trusts who hire us don’t have to pay for out for fuel, vehicle maintenance, staff training, equipment on the vehicles, pensions, sick pay or holiday pay along with many other overheads. Which in the long run saves trusts money on fines from targets not met if you didn’t have private crews picking up the slack. As for poorly trained! 80% of private staff are from trusts who are sick of trust politics and the poor wages, the rest is made of ex armed forces like myself and motivated individuals who actually want to work an not just clock watch or waiting till the last minute to green up. As a private paramedic who paid for my own training, we have the same qualifications as your trust crews and we are governed by the same body, we have to be whiter than white in the sense of jobs done and paper work completed due to some stuck up trust crews who are just too wiling to complain at the slightest issue. So for every private paramedic who you say is poorly trained I can show you a trust member who is under motivated. You can’t tar everyone with the same brush in this matter. I have personally backed up many a trust crew who have not had basic equipment like a tempanic or a bm kit or have missed something vital in there observations, but the difference is we don’t go running to complain. Our equipment is generally newer than trust crews due to the contract stating we can’t have vehicles under three years old an we carry the same life pack 15’s an drugs an an other equipment that makes a front line ambulbce work, we are regulary inspected by CQC just as your are. The shamefull thing is you made some good points on that post but started very poorly with a quick slating of the private sector. The private sector is here to stay regardless of your thoughts so you had best get used to it an start working as a team player rather than thinking your superior.

  9. Dakiro

    Interesting read.

  10. Kinglsey

    As an ambulance call taker, the above article is completely true. We have to send ambulances to people who seriously do not need one, but because they answer a question in a particular way, we have to go with it or fail an audit.

    We should be able to operate like police and fire control rooms, and actually have the ability to tell people when they are wasting our time instead of going through a ridiculous triage that 90% of the time serves no relevance to the situation, eg: crashed car at 15mph and get asked if they have passed bowel motions that are red in colour.

    The ambulance service as a whole has become a nanny foundation. Too afraid to tell people they are wasting emergency service time in case of repercussions, yet the police can do this and terminate the call. Our trust uses NHS Pathways which in my opinion, and the opinions of pretty much every call taker I work with, is a rubbish system, takes far too long, asks irrelevant questions (hence our opening statement of ‘I’m going to ask some questions, some may not seem relevant but answer as best you can’. We may as well just say to people we are going to ask them a load of crap that serves no relevance, please don’t shout at us so we can pass our audit, thanks.

    I’ve been in this for over a year now, and there are so many flaws its unreal. The government will say the system works. It doesn’t. People do need educating, but that will never start to happen when we are forced to accept and triage every single call, even from repeat callers.

    I understand that those new to the job would probably not see the above quite as much as someone who has done it for over a year, and I’d even go as far to say they should not be allowed to reject calls without additional training. However, after 6 months or so, you know the system inside out, you know at the start of the calls if someone is going to get an ambulance or not. You should then have the ability to tell people at the start rather than string them along for 15 minutes of crap triage to say they need to see a GP and get hurled abuse at.

    I feel sorry for the paramedics we have to dispatch, I really do feel for them with the rubbish they often get sent to.

  11. Chris

    Too true Alan, again a well written rebuttal.

  12. Kevin Stall

    I had a ambulance crew sit with me after a TIA stroke, to see if I needed to go in or able to just stay home. Luckily I didn’t need to go in. Ambulance is definitely better run than NHS.

  13. Lynne Roper

    Excellent article. One point; we no longer use AMPDS – the whole system from 999 to 111 uses NHS Pathways which is not, and never has been, fit for purpose. The practise of selling off 111 to the lowest bidder also precludes proper use of Pathways as a single triage system. It only works when networks of clinical supervision are put into place – i.e. it doesn’t work!

  14. Lynne Roper

    Having been sent by 111 to a woman having a period, a man wanting advice on how to take his prescribed meds (blue lips – CPOD!) and someone I’d sorted out the previous day who simply wanted to speak to an actual Out of Hours GP, I can tell you categorically that 111 is a nightmare. We can’t not fully assess unsuitable calls, so each takes a long time.
    The point being made here is that other agencies, often private (Care Homes and Holiday places in particular) use 999 as a way to cover their backs. All homes providing residential care for vulnerable people should be required by law to have a Registered Nurse on duty 24/7. When someone falls, they shouldn’t be left on the floor while the staff call 999 to check them over, unless they’re injured. When someone has a skin flap, the home should have transport available to take them to minor injuries, not call an ambulance to take them (and as local facilities close, often the round trip will be over 50 miles). Hotels and so on need to be contacted to explain why it’s not appropriate to call 999 for someone with a cut finger or a sprained ankle.
    It certainly isn’t easy working in triage call centres, but it would be a whole lot better were people taken to task for inappropriate calls.

  15. Clarky

    You may think it’s obnoxious but it is simply a fact that we are used as taxi drivers.

  16. Anonymous

    Actually it’s not fully factually true as a lot of Paramedics and EMTs are working for these private companies as a way of earning more money the equipment they use can be of a much higher standard to Ambulance services where there are shortages and items missing. Agreed there are some unqualified staff but to call all staff that work for these private firms as underqualified and unprofessional is very misleading and factually incorrect.

  17. Bob Mac

    might it be a solution to have paramedics staff the control room on a rotation basis say once a month? and do away with algorithms? With tasking HEMS, a senior paramedic does this as it is an expensive and scarce resource… well so are ambulances, so why not take this attitude?

  18. GTP2

    So your colleagues called an ambulance because they wanted the paramedics to check you over? What symptoms were they so concerned about that driving you to A&E themselves was not an option? You either have no idea what an emergency ambulance is for or you have missed the point of this article. There is a very limited number of ambulances and people with life threatening illnesses and injuries are having to wait because these ambulances are being used instead of common sense.

  19. Slut

    Pay you well to eh?

  20. neil666

    Well written, but the author should of done their homework as I am fairly sure AMPDS was scrapped when NHS pathways came into being, however I have to agree with many of the points made. This is not solely an ambulance service issue, the health system full stop cannot sustain the level of demand being placed upon it, but many if these issues are arising not solely from poor education or abuse of the system, but due to the current fiscal climate that means social care among other areas constantly under funded, and therefore fail those most at need. This on top of an ageing population and greater prominence of mental health issues is also compounding the issue.

  21. neil666

    This idea has been explored however I believe there is research that proves that clinicain involvement in dispatch can delay response through questioning and remote diagnosis.

  22. neil666

    Excellent response. Very well put

  23. Contusion

    A very large number of people working for private companies are actually nhs trained, or trained by ex nhs trainers, so it would be safe to say that the training for frontline private providers is exactly the same (otherwise they don’t clear to enter into the framework), the other section of private staff also pay for all training, so this doesn’t cost the tax payer any money, unlike nhs training. I read somewhere that an nhs ambulance costs around £250 an hour to run, I don’t think it’s ever passed on the cost of private ambulance being well under half that, some around £60 something an hour, for staff with the same qualifications….it’s always half the story that bitter people wish to share, and it’s supposed to be a caring industry?

  24. Contusion

    I posted this above, but backing up your comment seems a better spot…

    A very large number of people working for private companies are actually nhs trained, or trained by ex nhs trainers, so it would be safe to say that the training for frontline private providers is exactly the same (otherwise they don’t clear to enter into the framework), the other section of private staff also pay for all training, so this doesn’t cost the tax payer any money, unlike nhs training. I read somewhere that an nhs ambulance costs around £250 an hour to run, I don’t think it’s ever passed on the cost of private ambulance being well under half that, some around £60 something an hour, for staff with the same qualifications….it’s always half the story that bitter people wish to share, and it’s supposed to be a caring industry?

  25. txby

    I am a all handler for the east of England & yes we do still use AMPDS, very good article, we need to improve public awareness & GP’s not just out of hours.

  26. txby

    Unfortunately AMPDS is still used by east of England

  27. Lynne Roper

    Oh that’s interesting, I thought everyone had to change to Pathways? AMPDS was much better, though there were problems, but it was helped greatly because our dispatchers were able to use their knowledge, experience and judgement on it which is no longer allowed (computer says!).

  28. rob

    Before I joined the ambulance service I used to work in an ice rink. Naturally there were quite a few injuries but the policy was to only call an ambulance if it was a serious injury or they couldn’t walk. Arm/hand injuries were sent to A&E by taxi paid for by the ice rink. I was astonished to find this was not normal practice. Companies should be fined for unnecessary calls.

  29. David Fenwick

    Very well written fully agree with everything you said, something has to change.

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