The ambulance service: the past, present and future
Friday, June 1, 2012
Time to get serious about ‘transforming ambulance services’ and really taking health care to patientsThe second challenge has been recognised for some time and was the subject of a detailed study Life in the Fast Lane, published by the Audit Commission in 1998 (Audit Commission, 1998) and considered again in 2011 in the National Audit Offce's report Transforming Ambulance Services I (NAO, 2011). Both reports skirted the issues of what real transformation in terms of the concept of operation might look like, but they did make useful observations and suggestions. In some respects these findings paralleled an earlier American Ambulance Report authored by the legendary Jack Stout who set out the primary goals that all emergency ambulance services should strive for; response time reliability, clinical sophistication, customer satisfaction and economic efficiency (Stout, 1983; 2004).These principles would fall into what are often termed ‘lean’ management methods and derived from quality management theory (Ryan, 2002). Stout also provided a useful metric, ‘termed unit hour utilisation’, to determine the productivity of an ambulance service by simply dividing the number of patients transported, or patient contacts, by the availability of ambulance time expressed in hours (Stout, 1983). For example, an ambulance service producing four unit hours of ambulance time and moving one patient would be operating at a 0.25 level of utilisation/productivity. This simple system has yet to be widely adopted in the UK, although discussion regarding a standardised approach is now underway. However, a continuing quest for higher productivity and stronger response time performance will no longer be sufficient as the following points will illustrate.The diagram below (Figure 1) brings together the external forces and some counter-measures with the red line showing rising demand and the lower blue line refecting falling income. Bringing down the unit cost is therefore imperative through enhanced utilisation, (or improved productivity), shown in green. To address the current pressures caused by increasing low-acuity demand, the key strategic priority should be to recoup and reinvest a proportion of the funds derived from enhanced utilisation to develop new clinical capabilities, (income), while ensuring that conventional indicators of quality (activity), such as response time performance, patient safety, clinical governance and patient experience continually improve as well.Figure 1.‘Spinning plates,’ 5 priorities for Ambulance Service Leaders, dealing with reduced income and increased activity at a lower unit cost while maintaining clinical quality and introducing new clinical capabilities.In this context improved capabilities revolve around developing specialist paramedic practice to address patient needs in both primary and critical care as the primary means of making the system generate the productivity gains. Delivery of primary care would include the assessment and treatment of a wide range of clinical presentations such as wound management, near patient testing and a wide range of referral options. Critical Care would include patient assessment, the provision of a broader range of therapeutics, advanced airway management, cardiovascular support, and the introduction of new technologies such as ultrasound, to help guide treatment in the field, ideally with the provision of on-line support from more senior paramedics and medical staff where necessary.The conundrum for the ambulance services and the paramedic profession is how to continue to add value and improve quality in a financially constrained environment. Some might be tempted to reduce (or at least not to improve) clinical quality, or to settle for more traditional transport oriented concepts of operation. This approach fails to grasp the opportunities associated with the use of more highly qualified paramedics and specialist paramedic practice, which would unlock the prospect of delivering mobile health care and adopting a gate-keeping function. Such approaches are predicated on the basis that unnecessary transportation to hospital can have adverse financial consequences for the rest of the health economy and only works if the issue is considered at the ‘whole healthcare system’ level, rather than considering the ambulance service to be one of many silos.If the choice is to continue with the predominant transport model, it is likely that private ambulance providers will be able to accomplish this more cheaply than many existing NHS ambulance services, but at the expense of transmitting larger numbers of patients into overburdened emergency departments. An opportunity to develop an integrated, system-wide approach could be lost resulting in increased cost and clinical risk as large numbers of patients are unnecessarily taken to hospital, ramping up downstream costs.Clinical care came under the microscope in 2000, with an Ambulance Service Association sponsored paper outlining (Nicholl et al, 2000). This may have helped influence the 2001 Department of Health's glimmering of interest in widening the ambulance service's role in reforming emergency care (DH, 2001), spawning a veritable industry of regrettably seemingly alltoo-forgettable ‘reforming’ publications. These went largely unchallenged from the ambulance sector, but for the occasional cautionary note from commentators, including Judge, who questioned the scale and wisdom of the proposed changes in respect of the ambulance service (Judge, 2004). By 2005, Peter Bradley's Taking Health Care to the Patient (THCTTP) condensed these policy ideas and other initiatives into a document focused specifically on the ambulance service role. The report made the correct diagnosis but the implementation of the necessary changes was arguably poorly executed. The second report, (THCTTP2), was the closest the NHS ambulance services have had to current policy, but while some of the recommendations have seen some action, the failure to build them into the NHS operating framework and the lack of clear doctrine has attenuated the report's effect.
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