TRANSPORT SOLUTIONS
To deal with the growing need for more capacity, diffi cult decisions need to be made about ambulance service provision, says paramedic Jonathan Fox.
s resources become scarcer, the NHS will have to rethink the way it ap- proaches service provision in many areas.
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The ambulance service in England handles nearly eight million 999 calls every year, of which over 30% – around 2.5 million - are classed as category C, which is non-life threatening and non-urgent.
Jonathan Fox, a paramedic and the spokes- man for the Association of Professional Ambulance Personnel (APAP), said: “The problem and the challenge facing our pro- fession, both at a corporate and an individ- ual level, is how we manage this escalating demand on our profession.”
Given the nature of the ambulance crew’s work, making tough choices becomes even tougher because lives are at risk if the wrong choices are made.
Fox said there are few easy solutions. He told NHE: “Finding a way to deal with these issues is like trying to solve a Rubik’s Cube. The problem is that the ambulance serv- ice, as part of the 2005 Ambulance Service Review, has been working to reduce the pathways access to A&E by providing al- ternative pathways and ‘taking care to the patient’. That has necessitated the creation a higher level of paramedic called an emer- gency care practitioner (ECP).
“The problem is that dealing with non-ur- gent and non-life threatening calls in a clin- ically sound and safe way is very demand- ing and labour intensive and can take one to two hours per call. It is expensive and time consuming to train paramedics to be- come ECPs and, predictably, in the current fi nancial climate, their future is uncertain.
56 | national health executive Mar/Apr 11
“When you are handling anything up to 4,000-5,000 calls a day – as the London Ambulance Service is – you can under- stand why there is a situation where the reality and the theory of the plan are in many ways mutually exclusive.
“This is because it can be extremely diffi - cult to manage the non-urgent calls appro- priately when there are so many serious and life threatening 999 calls being han- dled by the control room. This is replicated throughout the country in other services.
“The pathways are fi ne – I use them my- self – but they are time consuming and to be ethically safe you have to spend a lot of time with patients.”
Don’t Send Policy
He adds: “Then there is the problem of people who call with issues for which they should be taking responsibility rather than calling 999. To a minority of people, the ambulance service is still seen as a conven- ient access point to the health care system and it simply adds to the pressure that the ambulance service is under.
“I was interviewed by the BBC in 2003 when London Ambulance trialled a ‘don’t send policy’. It was only a six month trial to essentially address the issue of category C calls and give the ambulance service the discretion not to send in certain circum- stances.
“This unfortunately never went any fur- ther. It came and went and was, apparent- ly, never followed up either in London or at a national level through the Department of Health. We continually have to manage
the inappropriate use of the service in tan- dem with the life threatening and serious emergencies that should be the principal focus of our attention.
“Stroke, heart and trauma patients often go to state-of-the-art facilities following interventions which we have applied at the scene following robust clinical deci- sion making processes made by ambu- lance crews.”
Otherwise Fit
For an ambulance service to utilise a ‘no send policy’ in certain circumstances is in- evitably a diffi cult decision – and can have grave consequences if made incorrectly.
It should be a part of a national policy to manage the inappropriate use of the serv- ice and not be left to an individual ambu- lance service to make that decision alone.
Fox explained: “Progress has been made, with nearly 9% of category C calls in 2009/10 being handled with clinical ad- vice over the phone – but that is on the premise that these patients accept that there are alternatives to being taken to hospital.
“During the swine fl u epidemic, despite the national advice to the contrary, we still had otherwise fi t young adults with fl u like symptoms calling 999 for an emergency ambulance. Unfortunately, this is not a hypothetical situation – this is the type of thing which does happen and is replicated frequently. It is simply not sustainable for the ambulance service to have call rate in- creases to continue by about 3-5% every year.”
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