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

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