Ten years ago, ambulance clinicians often perceived their role as responding to patients who had experienced an accident or acute medical emergency. Ambulance services concentrated almost entirely on the need to respond rapidly. While 80% of paramedic training was focused on this group of patients, the experience on the clinical frontline was somewhat different. Where were the endless time critical patients requiring multiple invasive interventions and medicines? The reality was that this group of patients represented less than 10% of the average ambulance workload. The remaining 90% were often labeled as inappropriate as their conditions were perceived as not increasing staff knowledge, testing their competencies or enabling the use of technical skills (Lewis and Bradbury, 1982). The last ten years has brought significant change in the way that ambulance services respond to these patients. Taking Healthcare to the Patient (Department of Health, 2005) recommended that ambulance clinicians should be equipped with a greater range of competencies to enable them to assess, treat, refer, or discharge an increasing number of patients in the community.
While ambulance services responded with increased telephone advice and the use of Specialist Paramedics/Emergency Care Practitioners (ECPs), the challenge was to expand the focus on reducing admissions to all grades of ambulance clinician. However, projects which focused on extending the standard skill set, such as the supply of prednisolone to asthmatics, or the direct referral of transient ischaemic attacks, often struggled to fit within both the internal and external expectations of ambulance services. With the non-conveyance challenge still in its infancy, the introduction of the ambulance clinical quality indicators (ACQIs) in 2010 signalled a change in the way that ambulance services view their priorities and measure their success. Evaluating the impact of ambulance services in delivering the right care to patients, in the right place and at the right time is very much the new focus.
In response to the need to further reduce the rate of conveyance to hospital, which was already consistently the lowest in the county, the South Western Ambulance Service (SWAST) introduced the Right care, right place, right time programme. The initiative continues to focus on a wide range of developments to improve the appropriateness of the care delivered to patients. The implementation of NHS Pathways, additional clinical supervisors and the development of a directory of services and capacity management system within the clinical hub (control centre) helps to ensure that ‘hear and treat’ pathways are used appropriately. Higher rates of non-conveyance inevitably result in the need for ambulance services to manage the more frequent and higher clinical risks which result. In parallel to developing methods of reducing conveyance, ambulance services must focus on the delivery of robust safety netting for every patient who remains on scene. This includes not only ensuring that ambulance clinicians have the appropriate training, but the provision of patient information and the routine passing of information to GPs. The inclusion of re-contact rates following both ‘hear and treat’ and 'see and treat’ within the AQIs, will hopefully help focus attention on ensuring the clinical safety of patients who are not conveyed.
Achieving the ‘Right Care’ agenda across the UK will require a shift in culture at all levels. Patient expectations require careful management; dialing 999 no longer automatically results in an emergency ambulance and a trip to the local emergency department. Ambulance services must empower their clinicians to make the right clinical decision for all patients, not just the critically ill minority.