A Draft Proposal

Somehow on my 'week off' I'm busier than I would be if I were just going to work. How am I ever going to get my full Spellfire set or my next six million ISK?

(OK, nerd episode over).

I've been spurred into writing this post for two reasons – the first is this post of mine and the associated comments, the second is this article in the Financial Times. Two quick notes on the article, if the government want to employ a blog expert I can be had for a salary of, oh lets say £25,000+. Also if they want to invite me to talk to them, I'm more than happy to spill my brains the general direction of anyone in government.

To recap – the main target that the government has set ambulance services around the country is that of ORCON. This, at it's simplest, states that we should reach our high priority calls in under eight minutes and our medium priority calls in under fourteen minutes.

The problem that I have with this is twofold. Firstly, in a supposed 'evidence-based' NHS there is little clinical reason for the eight minutes as opposed to four minutes. Secondly, and much more importantly in my opinion it directly impacts on patient care.

In order to meet the eight minute target ambulance services are removing double-crewed ambulances from the road in order to increase the number of Fast Response Units (FRUs). The reasoning is that if an FRU is on scene then the 'clock stops' and the job is a success. It's not a success for the FRU if they are stuck on scene with a stabbing, unresponsive asthmatics or with a child with meningitis.

People who are seriously sick need to be in hospital, not having a solo responder holding their hand while praying in desperation for an ambulance.

Ambulance folk can do a lot to stabilise a patient, but as a trainer of mine wisely says, “the place for a sick patient isn't the back of an ambulance”. Nor is it in their own home waiting for an ambulance to turn up.

So, what are we to do? We need to check on the performance of NHS trusts, that much is certain.

My solution is to have more targets.

But targets which will have an impact on patient care.

Lets have a target where we improve the number of heart attacks that we diagnose in the home and transfer to the 'gold standard' treatment centre. I think we are at 95-97% on that at the moment. How about improving the call to treatment time.

Lets have another target where we diagnose strokes (or 'brain attacks' in the jargon of today) and transport them to a specialist centre. Of course we might need a few more places to become specialist centres first, but isn't the NHS a 'joined up' organisation?

Lets have a target where we try to reduce the number of patients with asthma who need admitting to hospital. Better, lets reduce the number of people who need to stay in ITU because of asthma. Of course it isn't the sole job of the ambulance service to do this, but our targets should inform other aspects of the NHS, just as theirs affects ours.

How about improving the measurement and treatment of pain – its something that we aren't too good at, given that in most cases our choice of pain relief is restricted to entonox or morphine. We carry aspirin, but that is for heart attack treatment, not the treatment of minor pain. We also have paracetamol for children. How about nasal diamorphine? Improving the measurement and treatment of pain will directly improve patient's experiences.

How about improving cardiac arrest survival rates. We've managed to improve this greatly over the past few years and I'll be talking about this in a later post. Unfortunately the government doesn't 'reward' us due to our improvements in this area, perhaps they should.

Time until a patient is reached is important in some cases, so we'll keep a target for reaching patients, but lets change it to only having the clock stop when a proper double-crewed ambulance arrives on scene. The other targets (like cardiac arrest survival) will be met by FRUs getting there quickly, but this will mean that there is less chance of FRUs being manned at the expense of proper ambulances.

How about a target of increasing the amount of paramedic cover in an area. Or how about a target of improving the training of people on the road? Better trained staff means better care for patients.

Maybe a target to increase the number of ambulances on the road. Even better would be a target to have a certain amount of spare ambulances. Ambulances that are waiting for a call from a patient rather than the other way around. We should have a slight excess capacity of ambulances at all times, not have people waiting for ambulances to finish with one patient before they can be attended to.

Finally, how about a 'staff satisfaction' target – a happy workforce is a more effective workforce.

Some of these targets are more important than others and by giving individual targets a separate weighting we could come up with a total 'score' that will show improvement, but can also be broken down to show where further improvement can be made. For example the number of people who get diagnosed and treated at a specialist centre for a stroke could be worth ten times as much as the number of people who get painkillers for their broken arm.

We could even keep the ORCON target, but give it a more reasonable weighting of importance.

This system would have the advantage of being better based on current evidence and would highlight areas where changes can have an immediate effect on patient care and outcome.

There is a reason why I get a warm and fuzzy feeling when I diagnose and take to a specialist centre someone having a heart attack. It's because I've done something that will have an effect on the patients well-being. It's a feeling that I don't get when I reach somewhere in under eight minutes or meet an FRU who has been on scene for forty minutes.

Right – how do I get to be Minister In Charge of Sensible Ideas for Ambulances?

I've fiddled around a bit with this blog in an attempt to resolve some of the issues some people have had with getting a black screen when accessing the site. Let me know if it works out.

26 thoughts on “A Draft Proposal”

  1. Just a quick hi as this is my first post since finding this site which so accurately mirrors my feelings. Working as a radiographer in these wonderful times….Anyhoo –

    All hail to Mr Reynolds for Health Secretary. Scenario in our hospital… Government targets mean we have to try and save money (despite the 1.9Bn underspend…) so the hospital shuts some wards and saves cash. All good so far. The admissions ward then gets closed due to the dreaded winter vom/squirts virus. Patients now have to wait over the 4 hour target due to nowhere to send the patients to. So……. The hospital gets fined for breaching the 4 hours. If this is the way we have to work, then Mr Reynolds – you have more than my vote – i think just about everyone i work with…

  2. Emminently sensible, and most of seems to be “do-able”. Not sure any “business” would allow for things to be sitting around waiting but aside from that…There are parallels here with the growth in user-centred design you know. A lot of businesses are slowly realising that the customer is everything, and good customer satisfaction drives staff happiness, drives further improvements and so on.

    I HATE myself for couching this comment as a business focus, god knows the NHS is vital and wonderful and deserves twice, thrice, more! funding than it gets. Alas these days it's all about the monies though..

    That said, some of your suggestions seem viable and would make a huge difference. My only ever complaint about NHS is waiting times. When my wife had gall bladder complications (a stone lodged in there after the op to remove said bladder) the ambulance was quick, the staff helpful and friendly but it took some 4 hours to get her ANY pain relief and it took (to my shame) me standing in a corridor and berating a poor nurse at the top of my voice (I apologised afterwards with flowers and big tin of chocs).

    So, a little could go a long long way.

    You've got my vote!!

  3. All your suggestions have my vote too mate, as Gordon said, all emminently do-able and sensible.I got picked up by an ambulance when I dislocated my knee. The crew didn;t get to me for half an hour (which is perfectly understandable, dislocated knees are not life threatening, but they are bloody painful!) When they arrived, they gave me some much welcomed entanox, which gave me enough pain relief so they could move me (whilst stabilising the knee as it was still dislocated and they tried, but couldn't get it back in.) When I got in the back of the ambulance, the entanox ran out, and they didn;t have any more, nor did they have anything else they could give me. Apparently there was a discrepancy in their morphine stocks and until that was sorted they weren't allowed to carry anymore. So, the 20 minute journey to West Mid was not a comfy one!

  4. “Apparently there was a discrepancy in their morphine stocks and until that was sorted they weren't allowed to carry anymore. So, the 20 minute journey to West Mid was not a comfy one!”It is very messed up IMO that YOU paid for that – surely if there's a discrepancy ambulances should still have correct stocks to treat patients – you know, those buggardly things that waste money that could go on pointless wars and CCTV cameras.

    What next – an ambulance gets a hubcap stolen so the crew have to run around by foot until some auditor discovers what the problem is?

    I totally get the importance of not having morphine going missing, but FFS….

    Anyway, on a happeir note, great post mate, totally agree and would vote you in in a heartbeat!

  5. Excellent ideas, all actionable (to use pointy-haired boss-speak), practical, a good reflection of reality, and obviously put together by somebody who knows the facts.So they'll never do it.

    You'll notice there is no Ministry of (Anything) Sensible.

  6. I think the main problem with the current NHS targets is they fail to involve any “clinical need” into them. As you say getting an FRU quickly to someone isnt the best thing if they need to be taken to the hospital. A lot of the prioritising of cases clinicians used to do from experience is now taken over by meeting targets.Regarding specialist centres I did read a news story that if you're involved in a trauma case you're much more likely to survive if you're taken to a hospital that regularly deals with trauma compared to one that maybe only deals with one major trauma a month.

  7. A discrepency in the Morphine safe, suggests that the number present is less than the ammount recorded in the logbook and this in turn suggests a potential loss of a drug that can be life threatening. Should such a loss be discovered the required action is to seal the safe pending a police investigation, this is a legal requirement and was part of the agreement to allow such a dangerous drug to be issued to ambulance services. All of this action would not prevent a crew from going to another station to draw the drugs however that may not be practical.

  8. All sound completely reasonable suggestions and targets to me.Black screen has disappeared – yippee ;o)

    For info to those interested I passed the driving assessment for ECA with flying colours which shocked me so much (having followed the past history of our dear blogger…!!!) that I answered the completely ridiculous questions with such flipflopiness that they 'refused' me at the interview stage. Gutted, but hey c'est la vie – they don't know what they're missing… and I'll try in another county…

    Take care y'all

  9. You would get my vote Sir. A host of eminately sensible ideas there, the likes of which 50 thinktanks and spin merchants would take a decade concocting.Reynolds for Health Secretary!

  10. Black screen gone. Much better thanks.Been on nights myself so a few days behind but thought you'd like to know what happened in my trust recently. We have this “call connect” thing coming in. At present we have 8 minutes to arrive at a job from the time the job is passed to us. Next year this is changing to 8 minutes from the time the call is connected to the ambulance service. It's been estimated that this will knock our time down to about 6 and a half minutes to get there.

    To assess our ability to achieve this new target, our trust decided it would be a good idea to run a trial for a week. (All sounding good so far?) The week before the trial management put out an announcement that there was unlimited overtime available, and all available vehicles were returned to the road regardless of whether they were due a deep clean or a service.

    Hey. Guess what? We made it. We pulled it off and met the new target. So hey. Guess what? It's being implemented.

    Of course we have no chance whatsoever of achieving this in real life.

  11. Eminently sensible, so absolutely no chance whatsoever of implementation by the current shower of incompetents masquerading as HM Govt.Yup, black screen has gone – top job.



  12. Tom, haven't you realised by now phrases like The government and Sensible Ideas just don't go together.How many times can you recall anyone in authority asking you if any of their ideas are feasible?

  13. HAPPY BIRTHDAY!!for yesterday! Well I think it was your birthday! :s

    Am I right? Am I right?

    Anyway if it was your birthday, did you have a good one?


  14. Figures, Targets, Statistics. I would rather be dealing with patients, and seeing stats concerning how many of our patients survive MIs, CVAs, Cardiac Arrests etc etc.As someone who works in LAS Control, it sends me deolali to have a senior officer looking over my shoulder telling me that “The XXXXXXXX sector is performing badly”, even though – as far as I am aware – none of our patients has actually died. Apparently – according to the almighty ORCON – getting to a person in cardiac arrest in seven minutes, who dies is a GOOD result, but getting to a cardiac arrest in 10 minutes where the patient goes on to live a long and happy life is a BAD thing.

    Stop ambulances being sent to rubbish, institute a REAL No-Send policy, and let the staff who know what they are doing (both controllers and road staff) get on with the job that we ALL actually do very well!!!

  15. Thank you. Once again, a calm reasoned voice of sanity in a mad, mad world. I have enormous respect for your prosessionalism coupled with you passion for the job and the principles you hold fast to. I aspire to it myself and fall short every day.

  16. I am reading your novel at the moment and would just like to say there are many midwives who hugely appreciate the work you do. Esp. when you don't try to deliver the placenta! 🙂 So here is a big thank you from all of us.

  17. I don't think that there is any choice in 'Call connect' it's being brought in (as far as I know) by the government in order to combat some of the ambulance trust who may have been…ahem… slightly less than rigourously honest about their ORCON stats.I'm looking to do a study on crew safety and how that changes when call connect comes in in April.

  18. I love it when the placenta just 'drops out' and the midwife receiving has the hump with us.Trust me – we like avoiding work, so delivering the placenta is only more work for us…

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