Dear Editor, Reading your comment in Journal of Paramedic Practice 5(8) I fully agree with the conclusion that ambulance services need to be recognised as a care provider and not simply as a transport service.
However, we have a long way to go when ambulance services themselves see and use their paramedics as taxi drivers with first aid skills!
My own Trust does not allow us to ring a GP. Band 6 and band 7 paramedics are doing admin work, audits, disciplinaries, are responding on the car like any other paramedic or EMT, and are generally not available for a drop of glue, a steri-strip, an IO insertion or any ‘advanced’ clinical intervention like these. We are forced to make our transport decisions on a system based on the Manchester Triage System.
A system which, according to local hospitals, does not work very well but happens to be the brainchild of the medical director. These flow charts are incredibly rigid. Even if A&E alternatives were locally available the system leaves little or no space for any autonomous decision.
The section providing for leaving a patient at home under this scheme is even worse.
In order to leave somebody with a minor injury at home this patient needs to meet 14 criteria. One of them is that there should be ‘no break in the continuity of the skin excluding a minor abrasion.’
That means that (as actually happens) if we are called out to a fit and healthy 20-year-old with a minor laceration on his middle finger I should take him to hospital…A&E by lack of any Urgent Care facilities locally, in an emergency ambulance. Can you imagine the handover (and the cost)?
If you have the misfortune of being over 65 years of age and suffer a bump or scrape to your head you will have to go in no matter how fit and healthy you are. Because the criteria on the falls flow chart say so.
Of course we struggle with this practice and morale suffers no end. The only way around it is to get the patient to take responsibility by inviting them to refuse transport. Staff have become very proficient at this but that seems very unfair too. One can assume the patient is unable to make that decision for himself—that is why he/she rang 999 in the first place!
If we decide to ignore the flow chart and discharge the patient at scene, we leave ourselves wide open to negative consequences because our Trust will not back us—we went against the ‘guidelines’.
Once you have followed the flow chart and taken your patient on route to A&E there is a Pre-Hospital Warning Score to be calculated. This score should alert both the crew and the hospital to potentially rapidly deteriorating patients. The only problem is that it relies heavily on breathing and heart rate regardless of the cause, and it differs from the score the hospitals use. So a patient with a panic attack or an established COPD patient whom you take in with an infected toe will score high on this system and officially you should then ask the hospital for a standby. Hospitals do not take kindly to such abuse of resources.
The extremely worrying finding is that band 6 and 7 paramedics (are professing/starting to) believe in this practice and when questioned tend to point out that ‘it is for your own protection and such-and-such (high profile band 7 paramedic) never left anyone at home!’ It means we are creating a widespread culture of defensive medicine, increasing the burden unnecessarily on both ambulance services and A&E departments, while stripping paramedics of the power and habit to think for themselves.
Speaking of responsibility, I think that is one of the reasons why the NHS 111 project does not work. Unfortunately, people in this country generally do not take responsibility for themselves. If you look at it closely we are asking patients to diagnose/judge their condition and then decide whether to ring 111 or 999. Very few will consider the cost of calling out an ambulance any deterrent and the negative publicity around the 111 number certainly does not help. They feel an ache, a discomfort and a sense of entitlement will do the rest, while our response reinforces this behaviour. The only way around this is having clinically trained staff triaging on the phone before an inadequate American computer system kicks it into a major medical emergency requiring an emergency ambulance.
That takes courage; it means staff and Trust can't hide responsibility behind a computer system and it doesn't fit in well with defensive medicine based on restrictive protocols. That works both ways incidentally: the system churns out many false positives but most paramedics will have ample experience with the system underdiagnosing seriously ill people. It seems that, as a lay person and distressed family member, you have to remember to say a few ‘magic’ words to ensure a rapid response. ‘Chest pain’ and ‘difficulty breathing’ will do it, but if you describe your elderly parent's LVF presentation in any other words nobody will make haste; the computer system does not recognise that as a symptom of cardio-respiratory difficulty and control room staff are not allowed to divert from the protocol and ask sensible questions—it is the 999 version of 111.
And has anyone ever explained to the general public what ‘alert’ actually means? What are we to make of dispatch descriptions as: ‘patient is able to speak in full sentences but is not alert?’ All these trigger a Red2 response, on blues and twos because the computer focuses on ‘not alert’—and an automatic trip to A&E.
One would think that with the development of the paramedic profession these issues would die out and people would gain autonomy along with increased skills and knowledge. My employer, however, is one of the few Trusts in this country without a research structure and its medical director once said: ‘I am not interested in research, we don't need it, it doesn't work, fancy ideas only distract, while it costs money.’
As a result, people with advanced education, with degrees in emergency care and associated subjects, are doing admin work instead of providing advanced clinical interventions, clinical guidance and supervision. There are no trainers anymore to pick up on clinical issues, there is no training available on station and the week mandatory training once every two years consists of endless PowerPoint presentations about corporate policies and procedures, quizzes and, goodness, doing eight minutes CPR.
All focus is on the Clinical Performance Indicators, because they play a large part in the Trust achieving Foundation status. Yet despite admonishing emails urging road staff to improve these targets they do not get individual feedback. Because the data is hard to access if at all available and nobody has the time to extract them, analyse and give feedback.
Yes, we need to improve our standards, meet our targets and improve our efficiency. But I cannot help feeling that we are impoverishing our standards, are chasing the wrong targets and still waste an enormous amount of skills, talent and opportunity—and money. Some serious questions need to be asked—and answered—at the very top of our Ambulance Trusts.
The day the UK makes that decision the NHS will be on its way to recovery.
The author wished to remain anonymous