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Homelessness: implications for paramedic practice

February 2019

Key facts on homelessnessThe full extent of homelessness and rough sleeping in the UK is difficult to describe. Homelessness is recorded differently in each nation, and not all homeless people show up in official statistics. However, it is clear that homelessness and rough sleeping have been increasing substantially since a low point between 2009 and 2010.Statutory homelessness statistics reported that the local authorities in England had duty to accommodate just over 59 000 households in 2016–2017. This is a 48% increase on the 40 020 reported in 2009–2010. In addition, the estimated numbers of people who sleep rough have increased by 169% since 2010 to 4751 (Ministry of Housing, Communities and Local Government, 2018a; 2018b).

What is the long-term plan?

Acash- and resource-strapped NHS, repeatedly tasked with finding tens of billions in efficiency savings, and where funding gaps and cuts (alongside a rising demand) seems to have become a norm over the last decade. Now as we approach Brexit without any sign of a deal, a whole new string of problems are on the horizon for health care, health professionals and the patients you serve.

What is your ‘normal’?

I'm not convinced that a week can be normal when working in health care. The potential for an unusual or unexpected situation, outcome or presentation is ever present. In my previous column, I proffered that there is something comforting about the feeling of normality. Perhaps then, we attempt to comfort ourselves with thoughts of the mythical normal week? Is it perhaps possible that we have normalised the unusual? I suspect most of us still relish the diversity and variation associated with a role like ours. So as I settle down to write this column, I thought I'd review my past week and share some of my experiences.

Ignorance isn't bliss: behind the unequal distribution of end-of-life demand and cost

Variance in deaths and pressureClearly, some areas have more deaths than others, and Figure 1 shows the distribution of deaths per 1000 population across local government areas in the UK. Data are for 2017 and are from the Office for National Statistics (ONS) (2018a). The fewest deaths per 1000 population occur in London with the 14 lowest local authorities in the UK. Slough (5.3 deaths per 1000 population) comes in at number 15. At the other end, the top five local authorities (East Lindsey, Christchurch, Inverclyde, Rother, Tendring) all have more than 14 deaths per 1000 population. Of the four countries of the UK, Northern Ireland has the youngest population with only 8.6 deaths per 1000 population compared with 10.7 in Scotland. This inherent 5-times difference in deaths per 1000 population (as per Figure 1) therefore places markedly different end-of-life pressures on NHS organisations.Figure 1.Deaths per 1000 population in 2017 for local government areas and regions throughout the United KingdomThe last year of life is characterised by functional and cognitive decline and increasing dependence on carers for the activities of daily life (Rabbit et al, 2008; Kalbarczyk-Steclik and Nicinska, 2015; Aaltonen et al, 2017). Symptoms of anorexia, dyspnoea, fatigue and pain all increase (Singer et al, 2015); hence increasing numbers of falls and accidents resulting in fractures and other injuries along with indicators of failing immune function such as respiratory and other infections (Jones and Goldeck, 2014). Any forecast of future demand therefore must take trends in deaths into account along with the usual effects of age alone (Moore et al, 2017).

Homelessness: implications for paramedic practice

Protecting the mental health of UK paramedics

It is estimated that the average member of the public within the UK will experience one or maybe two traumatic situations in a lifetime—whether that be through witnessing or being involved in an accident, natural disaster, collision, medical episode or traumatic event. Those working in frontline emergency ambulance services however are exposed to distressing and traumatic events on a much more frequent basis (Halpern et al, 2012).

Redefining the ‘news’

Researching complex topics and demysifying useful information, sharing the stories of real people, writing, editing, polishing—these are some of the reasons I went into my profession. But when I carried out my master's in journalism, the drawn out United States-led war on Iraq was front-page news, while stories in health care (which had always been my area of interest) tended to focus on sensationalising research and scaring people away from just about every food (though to be fair, a large majority of our food has in fact been tampered with to a worrying degree—but that's a discussion for another day).

Building up a positive culture

In an unpredictable—and sometimes frightening—world, the few events that bring some normalcy can be really comforting. Christmas was never going to be white, New Year's Eve was always going to be busy and the question, ‘what's the worst thing you have ever seen?’ will forever follow social introductions to paramedics.

Student paramedics need funding too…

In 2018, a new student column shared perspectives from first, second and third year students across UK paramedicine programmes. This year, in a special quarterly feature, we will follow Eleanor Chapman, who has now graduated, on her journey as a newly qualified paramedic

Honouring inclusivity and support in paramedicine

Creating a brandIn a bid to create an identity for Proud@WMAS, the committee tried to design a new logo but quickly realised that the already established design had resonance with current staff and so it remained. The rainbow star of life, used by the National Ambulance LGBT Network, of which we are a contributing member, was agreed as it was felt that it would achieve uniformity across other ambulance organisations and enable the network to be recognised more easily. The committee sourced some funding to purchase 200 star of life pin badges which were distributed to staff across the Trust—they were so well received that a waiting list for badges had to be drawn! Why was the badge important? It allowed people to identify—not only as allies but also as advocates. When asked about the badge, people can spread the good work of the network.The network knew that work needed to be done to support not only our workforce, but also the diversity of the population we serve. A key part of this is the transgender community. The team began developing a Trans Awareness Programme for the Trust to increase awareness among operational staff, availability of information, training, and development of internal policy.It was on the back of this that a member of staff approached their line manager to notify them of their intention to transition from female to male. Their manager immediately contacted the network for support, not only to assist the manager but also to offer direct support to the staff member.

Brayden set to widen range of award-winning manikins

Brayden Baby: intuitive lights help improve CPR performanceCurrently under development, the Brayden Baby is designed with the help of key opinion leaders representing the ERC, national resuscitation councils and leading European paediatric institutions.Brayden Baby uses advanced sensors to detect and analyse the effectiveness of CPR. Sets of interrelated LED lights illuminate key performance indicators. Brayden Baby has intuitive lights to help guide the student to perform good quality ventilation, which is vital for successful resuscitation of an infant.Lights are also placed in the chest and illuminate to show correct compression depth, and blood circulation lights illuminate to represent the flow of blood from the heart to the brain. Additionally, it has a CPR-quality indicating light, which only illuminates when correct compression depth, compression rate and full chest release are performed—similar to the function in the award-winning Brayden manikin.

The nearness to death effect and why NHS pressures are going to intensify

Nearness to death effectSo, what have deaths to do with capacity pressures? There is a very simple answer: the nearness to death effect. The nearness to death effect has been documented for around four decades and shows that healthcare demand escalates with nearness to death and not with age, per se (Payne et al, 2007). Around half of a person's lifetime hospital inpatient admissions and bed occupancy is compressed into the last year of life (Hanlon et al, 1998). Hence, the marginal changes in deaths are intimately linked to the marginal changes in medical admissions (Jones, 2018a). If you ignore the nearness to death effect, you get the entirely false impression that it is all of those older people consuming the resources.For those who have been in the ambulance service for many years, have a moment's reflection around how Figure 1 may have influenced the marginal changes in the proportions of male and female ambulance journeys, especially since 2003. I think you have probably gathered the point.However, the issue regarding older people consuming all of the resources is addressed in Figure 2 where the age at death in 1974 is compared with that in 2017. Deaths in 1974 have been adjusted down to the same total as in 2017. As can be seen, in 1974, the bulk of deaths occurred below the age of 80; while in 2017, it is above age 80. The age of death has increased; hence, the nearness to death effect makes it seem that older people are clogging up the ambulances, etc. Nothing has changed. It has always been that the dying people (in their last year of life), irrespective of their age, drive the marginal pressures on NHS capacity.Figure 2.Age at death in 1974 compared with that in 2017Clearly, non-end-of-life NHS demand pressures are also age-related and Figure 3 attempts to disentangle how many admissions in the medical group of specialties may be a result of each source. Figure 3 makes such an estimate by assuming that every person has seven admissions (emergency and elective, including day case) in the last year of life. As is demonstrated, the proportion of admissions which are end-of-life-related rises with age except in the oldest old (age 90+). It is likely that the number of admissions in the last year of life may vary with age (especially in the oldest old). However, the principle is that the total admissions, ambulance journeys etc, rise in proportion to the speed of change in the population age-structure, relative to the rate of change in deaths.Figure 3.Calculated proportion of all admissions in England in 2017/18 which may be related to the end of lifeRegarding the rate of change in deaths, between 1991 and 2011, deaths in the UK were decreasing by around 4940 per annum. However, since 2011, they have been increasing by around 8840 per annum, and deaths have continued to increase throughout 2018 (Jones, 2018b). Hence, the end-of-life-based winter pressures in 2018/19 will indeed be worse than ever before—irrespective of whether or not there is an influenza outbreak! Influenza would only make a bad situation worse.

Emotional resilience in the ambulance service

This month, Ellie Daubney reflects on a difficult patient case she encountered on placement and the need for emotional resilience, support networks and self-care as a paramedic

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