There is much good sense in Sir Bruce Keogh’s  blueprint for urgent and emergency care across England, the latest in a long line.  It takes us back about ten years to when the Ambulance Services started to strongly develop into genuine healthcare providers rather than transporters.

The move was to imbed ambulance services into the NHS rather than have them semi attached as a kind of paramilitary adjunct scooping up casualties and dropping them off at the nearest A&E.  It was about treating patients where they were as much as moving them about. It was about getting an expert to the scene to triage what was the best response for the patient rather than sending a double crewed ambulance in response to every 999 call.  We saw the developing roles of Emergency Care Practitioners – super paramedics.  We saw that sometimes the nearest A&E might not be best and a longer journey might lead to a better outcome.  We saw ambulance service bidding to take on GP Out of Hours work and integrating the communications infrastructure.

We saw early attempts at building local databases of services available outside A&E (now the Directory of Services).  There were moves to allow even 999 patients to be taken to Walk in Centres or Urgent Care Centres which were beginning to be set up, rather than going to A&E.  Relationships were developed with Mental Health and Social Care out of hours teams and also with the then emerging NHS Direct; with collocation of teams.  We saw ideas around having extended triage of incoming calls using GPs and Consultants in control rooms and the idea that a 999 call might result in advice over the phone or an appointment with a GP.  It was about integration – now far more fashionable.

It was known then that up to 80% of 999 calls could result in satisfactory outcomes which did not involve blue lights and A&E.  It was also obvious (as least to some) that routing all other demands for urgent care through an integrated system that could align the needs of the patient to the services that were available was a good thing.  It all depended on the idea that there was a strategic view across a system with some overall governance, not a set of competing market players without any glue to make it work.

At least one ambulance service set out a strategy and consulted extensively with the public for a plan to have one single emergency care (included urgent care) system for a whole County (pop 1.5m) either through one organisation – an Emergency Care FT or through a tight network coordinated by the Ambulance Service through a single communications architecture.

Sadly what happened was that instead of vertical integration into core healthcare we got horizontal integration to make regional sized ambulance services.  This coincided with a policy shift to favour more competition generally.  The integration plan was to save money but it also ironically opened the door for the later fragmentation of emergency/urgent care.  It was a mistake, no doubt well intentioned, of historic significance.

We saw NHS leaders blaming the patients for not knowing what service they needed to contact, instead of realising that the system was incoherent.  We saw increasingly desperate attempts to promote the use of non A&E facilities like Walk in Centres to treat “minors” based on commissioner claims of cost saving and demand management which were entirely wrong.  Attendances at A&E and admissions from A&E continued to defy the optimistic claims by commissioners.

Fragmentation has continued as ambulance services lose contracts for patient transport; NHS 111 set up as a market pretty much collapses and GP Out of Hours also gets put out to competitive tender with predictable results.  The “system” is a total mess and the outcome is huge stresses on A&E Departments.

The latest Review goes some way towards recognising the role ambulance services could play but it might be a good starting point to dust off the plans made 10 years ago and implement them.

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  1. jenw17 says:

    The day before Good Friday, I needed an ambulance to take me to the local A&E. I was kept in over Easter because there was nobody in the hospital to interpret the MRI and CT scans that were taken.
    It was only on the Tuesday after Easter that it was realised that I had had an aortic dissection. Apparently 50% of people having these die before they get to the hospital, and 50% of those still alive die through misdiagnosis, so I am one of the lucky ones.
    How would Keogh’s rearrangement of ambulance services have helped me?
    Even the doctors in the hospital would have sent me home, probably to die, if my Sats had been 1% higher, because they could not work out what was wrong.

    1. Presumably under Keogh’s rearrangement your A&E would have been staffed with consultants 7/7 so that would help quite a lot with your problem.

  2. Whilst I would agree wholeheartedly with the sentiments expressed in this article, there are issues that ambulance personnel would raise, that conflict with some of the statements made.

    Here is a a document we produced which highlights what is happening in Gloucestershire, and I have no doubt is happening everywhere else in Britain today.


    All the information supplied in this document is direct from the mouths of front-line paramedics ( clinicians) and clinical care assistance (non clinicians).

    These same paramedics explain that the system of “Utopia,” used in A&E is the real crux of the problems ambulance staff encounter at hospitals.

    Utopia, means that all ambulances report to A&E and they then send patients to the appropriate wards for treatment. In days gone by, the doctor (GP) would arrange which ward the patient would be taken to, and care would be carried out from there, these days A&E gets log jammed because they have to triage every patient that the hospital accepts.

  3. S.p says:

    As someone who works for the ambulance service and like many others of my colleagues, we are very interested in what they are going to do with us over the next few years. There is not one person who doesn’t think it will be privatised in that time and we know how well privatisation works……
    We currently are so understaffed and working in vehicles so old it’s ridiculous.
    Pay and conditions are appalling. For them to say they want us to treat 50% of people at home with no support structure and basically doing a Drs work for less than a third of the money and less training is insulting. It won’t happen. The only way we cannot get in trouble is by taking people to E.D. We are not supported if ANY complaints come in and we do not have the equipment to leave people at home.
    Invest more than the 1% part of the NHS budget they get and it might make a difference. Pay, conditions, recruitment and equipment. Without this and there will be no change and potentially no service within a few years

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