Category Archives: Urgent Care

Advanced paramedics in England will be able to prescribe medicines to people who do not need hospital treatment, under new laws starting on Sunday.

 Who will be able to prescribe?

Advanced Paramedics  – those undertaking or having completed a Master’s-level (Level 7) qualification – will be allowed to complete a prescribing module, if their employed role has a need for it (i.e. you must be employed in a prescribing role, e.g. in a GP surgery. An AP cannot complete it if employed in a standard frontline paramedic role where prescribing is not a required qualification).

How does this fit with other professions?

Many other health professions can already prescribe. Nurses led the way, followed by various others including radiographers and chiropodists.

Will this mean frontline paramedics will prescribe?

No. To register, frontline paramedics have only completed a Bachelor’s-level qualification (Level 6) (from 2021), a Foundation level qualification (currently) or an in-work IHCD qualification (in the past), and therefore will not be able to apply for the prescribing module.

Why are paramedics being given the ability to prescribe?

Paramedics don’t just work in ambulances. We also work in GP surgeries, A&Es, walk-in centres, and Intensive Care Units across the country. Many of these roles are limited because the Advanced Paramedic, often employed alongside Advanced Nurses or other Advanded Allied Health Professionals, cannot prescribe, unlike their nurse & AHP counterparts. The change to the law will allow these to work equally to other professions, and will expand the number of range of jobs Paramedics can do (e.g. why employ an Advanced Paramedic who can’t prescribe, when you can employ an Advanced Nurse who can?).

Will there be any prescribing in the Ambulance setting?

Paramedic Prescribing is up to each Ambulance Service Trust to implement. There is certainly scope for benefiting the patient & the system if Advanced Paramedics are able to support frontline crews with prescribing skills. There are many cases where patients are taken to hospital or referred to the out-of-hours GP for a simple prescription that could, now, be handled by the ambulance service.

Is prescribing just for non-emergency cases?

No. Paramedic Prescribing will also widen the range of drugs paramedics are able to administer in an emergency when supported by an Advanced Paramedic. This too will be up to each Ambulance Service Trust to implement.

Won’t people just call for an ambulance for a prescription because its quicker than waiting to see a GP?

This question assumes that ambulances currently only go to emergency cases. This isn’t true, and we already attend many non-emergency cases that could/should be dealt with outside of the ambulance service. This has become the case through a combination of factors discussed in another article. Many of these patients, now they have entered an ambulance system ill-equipped and ill-trained to deal with their non-emergency health condition, are fed into the out of hours GP or hospital system.

Giving the ambulance service the ability to prescribe will not reduce the amount of non-emergency cases we attend, but it will reduce the onward burden of these cases to other health systems.

Furthermore, sometimes patients have multiple needs, some of which are urgent and some non-urgent, which may all contribute to an ambulance call-out. For example, a patient may have fallen and is unable to get up – a paramedic’s bread & butter – but the patient may also have an underlying chest infection or unmanaged chronic pain, which could have caused the fall.

Say you’re wrong. What happens if calls for non-urgent cases do increase?

The underlying issue here is that the Ambulance Services are already stretched between trying to provide quality care to both emergency and non-emergency groups. The concern highlighted in this question is that this tension may increase further if the patients begin to use the ambulance service in order to obtain a prescription quicker.

The solution is not to stop ambulance services from prescribing in order to manage the tension, but to look at the systems that bring about the tension in the first place.

Here I wrote how current ambulance services might overhaul the system by providing only emergency care, while another group of paramedics, either still employed by the ambulance service but with exclusive resources, or employed by new non-emergency ambulance services or by GP surgeries themselves, could handle non-emergency care.

Paramedic Prescribing increases the ambulance services ability to provide 24 hour care in the community, independent of other services, across a whole range of acuities.

This provides a potential solution to the increasing difficulty found by General Practitioners to be able to afford to conduct home visits and to provide out of hours care. Ambulance Services have held GP visits & OOH GP contracts in the past, and have delivered well. As long as we ensure that this doesn’t impact the emergency care delivery, ambulance services could reshape the landscape of care in the community.

Where can I find out more?

The College of Paramedics has led the campaign for paramedic prescribing, and has a lot of good information and documents on their website.

 

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The National Audit Office documents only failure in its ‘Reducing Emergency Admissions’ report

On 1 March 2018, the National Audit Office published a damning report on successive failed initiatives to reduce emergency admissions at NHS hospitals in England. The National Audit Office scrutinises public spending and holds Parliament to account and improve public services. Apparently the Department of Health  wants elective and emergency admissions to be reduced to 1.5% (whatever that means). The NHS England mandate is however extremely weak in the admissions arena. – ‘…to achieve a measurable reduction in emergency admissions by 2020’.

Cost is a big issue here and reducing mortality and patient pain and suffering makes no appearance in the 54 page report. The current annual cost of emergency hospital admissions is £13.7 billion. This cost has remained static over recent years. Between 2015/16 and 2016/17 emergency admissions increased by 2.1 %. So all attempts over recent years to reduce emergency admissions have failed.

The elephant in the room here is the oft quoted 2009 McKinsey & Co theory that 40% of patients admitted to hospital should not be there. The theory continues with the notion that Out of Hospital/community care/intermediate services could ‘replace’ these hospital admissions. NHS England states that currently 24% of emergency admissions could be avoided.

79% of the growth in emergency admissions from 2013/14 to 2016/17 was by people who did not stay overnight in hospital. Reducing beds (bed use) is clearly a key factor as staying overnight in hospital is expensive. The emergency admissions’ increase is mostly of older people.

It’s pretty clear that attempts to reduce the impact of emergency admissions have failed. These reduction programmes include the urgent and emergency care programme, the new care models, the Better Care Fund, RightCare and Getting It Right First Time.  Re-admittance rates rose by 22.8% between 2012/13 and 2016/17.

In October 2017 the Department of Health admitted that £10 billion spent on community care ‘could have been better used’ and that ‘programmes to focus on community care had stalled’.

The Department of Health, NHS England and NHS Improvement all admit that they have no idea why there are local variations in hospital emergency admissions. NHS England is not happy with emergency admission data, and the lack of linked data across healthcare and social care.

On page 10 of the report we find ‘…the challenge of managing emergency admissions is far from being under control’.

There are enormous amounts of data analysis on performance, beds and intermediate care.

The number of days that beds are used by people admitted as emergency admissions has increased from 32.4 million in 2013/14 to 33.59 million in 2016/17 – an increase of 3.6%. The majority of bed days (96% in 2016/17) are used by people who stay for two days or more after being admitted as an emergency admission.

The recommendations in the report are stunning and include:

  • Establish an evidence base
  • Disseminate learning on new care models effectively
  • Link primary, community health and social care data
  • Figure out why there are local variations in emergency admissions
  • Figure out how community services will support reductions in emergency admissions
  • Introduce an Emergency Data Care Set to improve data on daycase emergency care
  • Publish data on re-admissions.

View the NAO report 

 

1 Comment

A socialist analysis of any health programme requires recognition of the competing tensions of resource, patient care and working conditions, and the necessity of balance to prevent a crisis. Therefore, the following analysis will reflect these tensions. Finally, I will analyse the crisis points which caused this to be necessary. During this analysis, I will exclude increased funding as a consideration, due to the low liklihood under the current government, and because increased funding would ameliorate, but not solve, some of the underlying problems.

The Ambulance Response Programme

The Ambulance Response Programme was the largest overhaul of the way the ambulance services deals with calls for 20 years, and was trialled in the West Midlands, South West and Yorkshire Ambulance Services from 2015, before now being rolled out to other services.

The major changes that the ARP brought about were:

  1. Increased time to assess call requirement before resource allocation (through new ‘Nature of Call’ and ‘Dispatch on Disposition’ processes)
  2. Increased number of categories with longer response times

Prior to the ARP, calls were broadly coded as follows:

Category Call examples Response Time Target
Red 1 Cardiac Arrest, choking 8 minutes
Red 2 Chest Pain, Shortness of Breath, Heavy Bleeding 8 minutes
Green (1-4, local variation) Everything else 19 minutes

After a series of trial and error, the latest iteration of the ARP codes calls as follows:

Category Call examples Response Time Target
1 Cardiac Arrest, actively fitting, <5 year old with priority symptoms 8 minutes
2 Chest Pain, Shortness of Breath, Heavy Bleeding 19 minutes
3 Nosebleeds, headaches, other urgent health complaints, concern for welfare 60 minutes
4 Fall without injury 90 minutes

Analysis: Old vs New

Resource efficiency

Efficiency is important, no matter your political position. However, the motive for efficiency is key. Clearly, it was inefficient for 50% of ambulance calls to be responded to within 8 minutes, especially considering the 90%+ rate of false positives (University of Sheffield, 2017). This was both detrimental to patients who couldn’t get an ambulance, and workers who dealt with the stress of demand. Therefore, better ways of matching clinical need to resources were required.

There is detailed evidence-based analysis provided by the University of Sheffield (2017) (Presentation, Final Report) regarding the effect of the ARP on resource efficiency. As they make a much better argument than I can, I will only summarise their main findings:

  • Increased time to correctly assess calls before resource allocation has resulted in increased operational efficiency on all measures, and subsequently better response times for seriously ill patients.
  • The change in call categorisation is a large overhaul and still in its infancy, and many adjustments are yet to be made, however, the initial results reveal that resource allocation more closely matches clinical need, and reports from staff in EOC appear positive.

While it has clearly been driven in response to decreased funding to meet rising demand, the important question to be made is whether this efficiency has been beneficial to patients and workers, or whether it has been solely to meet a wider agenda.

Effect on patient care

 It is easy to take away headlines such as “Patients will wait 20 minutes instead of 8 minutes when having a heart attack”, but it is obviously more complex mechanism than that. Of course, ideal conditions and unlimited funding would lead to an ambulance on every street, but reality imposes constraints, even in a well-funded health system such as one under a Labour government.

It is important to recognise what the numbers mean. The numbers are arbitrary and represent a target (i.e. 75% of Category 1 calls responded to within 8 minutes) by which to measure performance and evaluate the effectiveness of changes. So the changes that have been made to call categorisation are only to increase the number of categories and to what delay is deemed acceptable for each category. The number of minutes can be changed at any time. That being said, studies have shown that there is no clinical benefit for response in less than 8 minutes for any condition other than out-of-hospital cardiac arrest (University of Sheffield, 2017).

Where efficiency has been gained is because of the greater time allowed to ambulance controllers to send an appropriate resource (e.g. one that may be about to come clear close to the incident), rather than forcing controllers to dispatch resources immediately, only to stand them down once half way across the city. This is especially evident when one considers the maximum response time for an emergency call was previously 19 minutes, even for very low-urgency calls (e.g. minor ailments such as a cold) – it is now 90 minutes, allowing controllers plenty of time to allocate a resource while ensuring emergency needs are met.

One unintended side-effect that has had a detrimental impact on patients arises due to the change in the ability of Rapid Response Vehicles (RRV) to ‘stop the clock’. RRVs were located in many rural towns, where being highly localised enabled them to have a good relationship with other health care providers (impossible in the urban environment), were manned by experienced paramedics who were highly skilled in the use of alternative pathways. Not only this, they were able to provide rapid response in time-critical conditions. In summary, RRVs were good for patient care.

From a performance target perspective, they were able to ‘stop the clock’, which financially justified the lack of ambulance provision to these rural areas and their presence masked the long (several hour at times) waits for a conveying ambulance to arrive (which wasn’t a performance target). This tragedy led to the removal of ability of RRVs to ‘stop the clock’ when it was apparent a conveying ambulance was required (e.g. elderly fall with hip pain). In practice, what has happened is, in organisations forced by policy makers to place meeting budget requirements above patient care, that the financial justification for RRVs disappeared and the RRVs were quickly replaced by ambulances, which spend a long time away from their locality conveying to city A&Es leaving those rural areas with little or no cover. The towns involved have rightly been incredibly angry at this change.

Clearly, a middle way is required in this circumstance, and it is imperative that NHS policy makers recognise the unintended side effect of their decision and adjust accordingly.

It is a complex picture to say whether this change has benefited patient care overall. While I would like no-one to wait a long time for an ambulance, a utilitarian approach must be taken – the greatest amount of good for the greatest amount of patients. Patients who are uncomfortable but stable, (e.g. elderly fall with no injury) might now be waiting longer for ambulances, but that means resources are available to reach seriously ill patients quicker.

The major confounding factor in the analysis of the ARP is the inability of current triage systems to differentiate between emergency and urgent conditions in some circumstances, leading to symptoms becoming groups to be dealt with together. A triage system that could sort heart attacks from other non-emergency causes of chest pain would enable, for example only, a 8 minute response to one, and a 40 minute response to the other. However, the computer triage system treats all chest pains as one common group. As a result of this, the previous categorisation system took the lowest common denominator and required an 8 minute response to all chest pains – which, along with other similar processes, proved unsustainable without massive increases in funding that’d be eye watering even under socialist governments. The current categorisation system, therefore, has had to compromise, allowing Ambulance Services a faster response than necessary to some chest pains, but a slower response than necessary for others. The weakness of computer triage systems will be examined briefly later in this analysis.

Effect on workers

 The effect of ARP on ambulance clinicians has been positive on the whole. The major concerns of Ambulance Clinicians are finishing on time, getting a break, and fatigue, including blue light driving fatigue.

Prior to the ARP, it was common to respond to a call for a low urgency condition only minutes before you were relieved by an oncoming crew.

The increased number of categories, and the increase in time allowed to respond to urgent and non-urgent calls has allowed unions to push for improved end-of-shift policies and break policies, for example, not responding to calls with a 60 or 90 minute response time within the last hour of your shift, and getting a break halfway through the shift unless there is an outstanding emergency call. Both of these policies represent major steps forward in ambulance working conditions only made possible through the ARP. No figures have been released around whether these policies have decreased late finishes and late breaks (and of course, there are many confounding factors), but I believe the positive conclusion follows logically.

The inefficiency of the previous system led quickly to crew fatigue. While, of course, fatigue is still a major issue for ambulance crews, a small amount of the burden has been improved.

Many outsiders find it hard to believe that blue lights & sirens are used to go to every call, from stubbed toes to shaving cuts and to mothers struggling to get their baby to sleep (I’ve been to all 3!).  This policy, suited to an era gone by where few calls were not life threatening emergencies, is still enforced by Trusts in the name of benefit to the patient, but it is widely believed on the frontline that the motive is purely financial (less time driving between jobs means more jobs achieved during the shift). Driving on blue lights is fatiguing, especially in rural environments where you may be driving for an hour routinely. One major shift represented within the ARP is the recognition that some responses (Category 4) don’t require a blue light response – again, reducing the burden of fatigue. In reality, few conditions benefit from blue light responses, and the correct solution would be a flexible approach: allowing the clinician to make the decision according to weather & traffic conditions and clinical need, rather than rigid blanket rules.

Fundamental tensions: is there a better way than ARP?

Now, one must ask, why was such an overhaul of response times necessary? It is only by addressing the fundamental tensions that led to such a change occurring that it would be possible to improve on ARP.

While it was certainly correct to move away from old systems of working, the driving factors arise from two points – the tension between emergency and urgent care within the Ambulance Service and the high rate of false positives as a result of computer triage systems – both of which are subjects for in-depth analysis themselves, but about which I will make only a brief assessment.

Demand for emergency pre-hospital care is what the Ambulance Service evolved to supply, and almost everything within the Ambulance Service is oriented to this demand, including previous systems of call categorisation, the medication & equipment we carry and our training. It also evolved in an evironment where 999 was infrequently used by patients for urgent healthcare. However, due to austerity in other areas, especially General Practice, Mental Health and Social Services, patients have turned to 999 (and now, 111) to meet their urgent needs. In simplest terms, the Ambulance Service is overwhelmed by urgent and primary care requests, such that when a time-critical emergency occurs, there are few or no resources to respond. The ARP is a clear shift in ambulance service policy to attempt to more efficiently bridge this tension between emergency and urgent care.

This tension is fundamental within the Ambulance Service, yet is little debated in absolute terms in the public realm. While reversing austerity in GP, MH and local authorities would reduce ambulance urgent care demand, the tension remains beneath the surface. Not only that, ambulance clinicians have shown that they have a place in supporting medicine in the community.

The reality is that no single pool of resources can meet demand for both urgent care and emergency care without one or both suffering, and therefore exclusive resources must be allocated for each purpose, probably through split emergency and non-emergency organisations (potentially into 999 & 111, Fire Service & Ambulance Service, or new organisations entirely). Implicit in this is the recognition that emergency care requires resources in reserve.

The system that made ambulance services vulnerable to the increase in urgent care calls is the use of a computer triage system which will always be designed to be near risk-free. While it brings benefits such as standardisation and ability to audit, its weakness is the removal of the human subjective element from it. The easiest example to illustrate is that of Chest Pains: A risk-free computer system will be designed to miss no heart attacks, and therefore every chest, back or jaw pain is treated as a heart attack, despite that call being for 10 year old back pain, or for dental problems. The system churns out a high number of false positives of many conditions, stretching resources such that they are unable to attend the true positives. It is due to this that over 50% of ambulance calls required 8 minute responses under the old categorisation system.

Regarding solutions, due to the non-standard presentation of medical conditions, it would near-impossible to improve the false positive rate through question refinement (e.g. at what duration of chest pain do you not treat it as a heart attack? Do they have to say “crushing chest pain”?). The job of clinicians, however, is to consider many subjective factors simultaneously and come to a conclusion as to the likelihood of a condition being present. The weakness of clinicians, on the other hand, is that they make mistakes, and their telephone clinical assessment could delay response. The return of clinicians to call-taking is expensive and introduces some risk, but would produce system wide benefits in reducing ambulance responses, and therefore improving response times to seriously ill patients.

One further question on which there has been no debate is: if it has been deemed safe for a patient to wait 60 minutes for an ambulance, but ultimately will require admission, and they live only 10 minutes from the hospital, should they receive an ambulance or be told to make their own way to A&E? In many cases, asking them to wait for an ambulance, when they could make their own way only serves to delay treatment, which is unethical.

The question that must ultimately be asked is whether they should receive an emergency ambulance at all, if their condition is so stable. I do not propose leaving such people without care at all, but I return to my previous point on the tension between emergency and urgent care. I merely propose that other forms of urgent care services could meet this demand better, and from a resource perspective, patients with urgent care conditions who can make their own way to A&E or other services should be encouraged to.

Only a brief assessment of these factors has been made here, as a true assessment must be far more in-depth than this analysis allows, and I hope to elaborate on these issues more in future.

Conclusion

The ARP, though still early on, has appeared to have improved resource efficiency, have had a broadly positive effect on patient care for the most seriously ill patients, and allowed unions greater scope to develop better working conditions. I can find no reason for socialists to oppose this change.  However, socialists must look beyond surface symptoms for deeper tensions, and by understanding and attempting to resolve these tensions, alongside others, it is possible to improve patient care, working conditions, and resource efficiency at a magnitude far greater than current attempts.

Further reading would be the in-depth report by the University of Sheffield, which provides a detailed background and evidence based analysis on its effect on resource efficiency.

James Angove is a pseudonym. The author is a socialist and a paramedic in the UK, whose identity must be hidden due to the treatment of health care professionals and other whistleblowers who talk about issues within the health service.

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Demand has grown for the Ambulance Services by 35% since 2010. While the government announce that the budget has seen a 16% increase in budget since 2010 (National Audit Office, 2017), in reality matching inflation counts for 12% of this increase. This demand is not predominantly the ‘living longer effect’: while that of course does play a part, aging is largely a predictable variable and with effective planning could have been corrected for many years ago. The increase in demand comes largely from four areas: undifferentiated urgent care complaints; failed secondary care; mental health problems; and social care problems. All the above have occurred as a response to the cuts seen in Primary Care, Hospital, Mental Health and Local Council budgets. In this first of a series of articles, we will focus on the effect of cuts to primary care and the shift from GP provision to Ambulance provision as a result.

Ambulance services

Ambulances outside the Accident and Emergency Dept

During this article, I will refer to urgent and primary care interchangeably. This is because the classification for ambulance is ‘urgent’, where many of these patients should be managed in primary care. Many of the concepts of which I speak here are not the subject of research. I have linked to evidence where possible, but much of what I say comes from personal experience, and from talking to other ambulance clinicians around the country.

The Ambulance Services used to deal with, largely, emergency care. The perception of this remains, but it masks the true nature of today’s Ambulance Service. A mobile GP surgery, with none of the equipment, training or support. Older paramedics reminisce of days gone by where they only went to “genuine calls” – heart attacks, respiratory problems, road traffic collisions and cardiac arrests. Today, these make up only a small percentage of call outs. Today, we go to a variety of calls from mild belly ache, urine and chest infections to “baby won’t settle”, months-old complaints of back pain and other primary care conditions.

While this may appear on the surface as misuse, and therefore an issue of public ignorance towards the severity threshold for a 999 call, as many clinicians and social media users alike will propose, there are underlying processes at work that socialists must examine.

Many patients will talk on crew arrival of the immense difficulties they have undergone to try to get an appointment with a GP, only to either be instructed to call 999 as the surgery, under immense pressure themselves, are unable to assess the patient within a safe timeframe, or to be told the nearest appointment is in 3 weeks, to which many concerned relatives will see no choice but to seek a quicker assessment – and none are quicker than the ambulance service, despite increased waiting times. Others have been referred by the 111 service which has a notorious infamy amongst ambulance clinicians for referring a large number of false positives – and missing false negatives.

Some may reply that if Ambulances are sat around waiting for emergency calls, and GPs are overstretched, then we should be available to help. While I shall deal with the issue of the need for a ‘reserve’ within the ambulance capabilities later on in this series, it is also important to examine how we deal with these primary care cases.

At no point do Emergency Care Assistants, Emergency Medical Technicians, Associate Ambulance Practitioners or even Paramedics receive training in the management of urgent or primary care cases. Our guidelines make no provision for it either. Our assessment training only covers so far as to identify conditions that fall under the Emergency remit (Strokes, heart attacks, pulmonary embolisms etc.). Due to the lack of training, many do not have the confidence to make decisions on primary and urgent care cases, fearful of missing an atypical heart attack or other hidden emergency condition and such like. Alongside the perception of lack of support from employers and regulatory bodies (which does not always align with the evidence), this leads to an inordinate number of conveyances to A&E “just in case” – and not always in the patient’s best interest.

Our assessment equipment, again, is tailored to emergency situations – electrocardiograms, blood sugar tests (in case of an unconscious diabetic), oxygen saturation probes – and we lack the necessary equipment to make primary care decisions. For example, “Dipping” urine is a very simple skill, no more difficult than a litmus test or an old pregnancy test, such that relatives and patients are sometimes taught to use it. However, paramedics are unable to “dip” urine, with no explanation given (one can only assume a cost factor), needing for us to rely on District Nurses, GPs and A&E to conduct the urinanalysis, delaying diagnosis and treatment for a common elderly condition, which can progress to life-threatening sepsis if left untreated.

Not only this, but we carry only enough medication to prolong or save life in emergency situations – adrenaline, salbutamol, and morphine among others. Even if we correctly assess the primary or urgent care complaint, we have no management tools. We carry no long-term antibiotics (and maybe for good reason with a view to antibiotic resistance, but it has implications if we are to respond to these jobs). We can offer nothing for long-term pain management (only enough to move an in-pain individual to hospital). Again, with GPs unable to fit in appointments, this leads to a large number of conveyances to A&E as ambulance clinicians (rightly) view it as unethical to delay treatment, even if A&E are over-stretched.

The biggest problem caused by ambulance response to primary care is the lack of emergency reserve. I personally have heard so many calls from the Control Room pleading over the radio for someone to make themselves available to respond to hyper-time critical emergency events like choking, fitting or cardiac arrest, because the closest crew is 20 minutes away being drafted in from another city. Amongst other causes of increased demand (mental health and social care), this is because closer ambulances are dealing with primary care conditions. A major source of stress for ambulance clinicians is knowing you’re only a few minutes away from a time-critical emergency, but being unable to leave the primary care patient you’re currently dealing with.

However, there are advantages that are appearing as the ambulance profession absorbs primary care into its remit. An obvious example is care for patients who are unable to leave their home due to current or past medical conditions or their age. Traditionally dealt with by visits by their GP, these patients are left without care out of hours (except by out-of-hours GP visits) and struggle to ever be seen by health care professionals due to cuts to both in-hour and out-of-hour GP provision. A more detailed argument would be required by someone with experience in GP Primary Care provision dealing with whether home visits are an efficient and appropriate use of a GP’s time (as opposed to other HCPs). Ambulance clinicians are traditionally mobile and used to working in people’s homes, and are now used to dealing with some primary care complaints, could be one alternative. Before the Ambulance Service merger, Staffordshire Ambulance Service conducted GP Home visits on behalf of many surgeries, and provided the out-of-hours provision. This was backed up by training, good local working relationships, equipment and a more advanced management portfolio than the one provided to clinicians in the same region now.

Another advantage is that paramedics are more regularly exposed to emergency patients than GPs, which gives them skills and experience that would assist GP assessment and to start the pre-hospital management of emergency care. One example of such a skill is that paramedics are fast becoming experts in 12 Lead ECG interpretation, and with this skill being almost routine, paramedics would be well placed in GP surgeries to provide an additional experienced opinion. Cardiac arrests are an uncommon occurrence within a GP surgery, and no matter how well a clinician knows the theory and has memorized the protocols, the management of this condition is difficult out of hospital, especially for clinicians who don’t have regular exposure to it. This is another example where ambulance clinicians who have a lot of real life, hands on experience with out of hospital cardiac arrest, would help primary care providers deliver effective care.

The two competing processes of dealing with urgent care and emergency care represent a tension that at times, such as winter, represents a crisis. In simpler terms, Ambulance Services struggle to provide a timely response to emergency care by being tied up in urgent care, and, as society’s last line, leave urgent patients without access to care due to dealing with higher priority requests (e.g. reports of elderly ladies left on the floor for hours).

So, what is the solution?

First and foremost, GP surgeries require sufficient funding to make sure no-one waits an unethical amount of time for an appointment. If Ambulance clinicians are to respond to primary care calls, clinicians should receive the correct training, equipment, management tools and support from GPs to provide the right care to the patient.

However, no amount of amelioration will resolve the contradiction. One set of resources balancing the two types of care will always be only one disturbance from crisis, no matter how well balanced it may appear.  What is appearing as the most fundamental requirement of any solution is that exclusive pools of resources to deal with each category of demand is required.

To achieve this, Emergency Ambulance Services should not take responsibility for responding to these primary care/urgent calls, and responsibility should pass to another group of resources. Possible splits could be for emergency care to pass to the fire service, or for urgent care to be taken up by the 111 service. It would also be possible for a split to occur within the ambulance service, much how the Patient Transport Service or the High Dependency service operates separately from Emergency care.

However, my suggestion is instead for non-emergency ambulances staffed by specialised urgent/primary care paramedics with the necessary equipment to be attached to individual GP surgeries, with a good working relationship with the surgery staff, that can carry out home and urgent visits at all hours. For clinical governance purposes, they could be managed by a national non-emergency ambulance organisation, while being paid and employed by the GP surgery.

The reasons I believe this to be the correct solution are:

  • Continuity of care for patients with acute exacerbations of chronic conditions, which is good for both the patient and helps clinicians make good decisions
  • Ambulance Crews are able to access a patient’s medical records to make informed decisions
  • A good working relationship between ambulance clinicians and GPs is difficult to achieve in many urban areas, due to the large number of regionally employed ambulance crews and the multitude of localised GP surgeries, however, one must only look to community paramedics based in rural villages and their relationship with the local GPs to see the increased benefit for the patient and the wider NHS.
  • A clear delineation between Primary/Urgent GP care, Emergency Ambulance Care and Secondary Care, where currently the lines are currently very blurred, allowing for correct training and equipment.
  • An embracing of the advantages of ambulance clinician primary care

The Socialist Health Association should oppose any attempt to load further primary or urgent care on to Emergency Ambulance Services – either directly, or indirectly through further GP cuts. The SHA should recognise the internal contradiction and its effect on patient care, and to call for primary care provision to return to GP services, allowing emergency ambulance services to have crews available to respond to true emergencies. However, the SHA should embrace the positives of mobile primary care response units and the unique experience of ambulance clinicians and call for ambulance clinicians to become more involved in primary care provision in GP surgeries through a number of possible mechanisms.

James Angove is a pseudonym. The author is a socialist and a paramedic in the UK, whose identity must be hidden due to the treatment of health care professionals and other whistleblowers who talk about issues within the health service.

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I am just writing this as me. It isn’t going to be the most perfect piece of prose, partly because the information has come from my husband/carer and because I still feel the fear whenever I think about it. My brush with co-payments was traumatising for me, my husband and could have had very serious consequences – including death.

I live with a rare, and potentially fatal condition. It has been what they call “brittle” from the beginning. Nevertheless, I am well insured and of course carry all necessary documents for health treatment in an EU country. What could possibly go wrong??

Early one morning while on holiday in an EU country I started to feel nauseous. This is a warning sign of a crisis. The nausea progressed to projectile vomiting, then voiding, as my temperature plummeted and I began to lose consciousness. My husband phoned the local health centre. They spoke English and he fully explained the danger – left too long my organs will shut down, and the end game is potentially death.

The first words spoken were – “that will cost you 180 euros. “OK” said husband, but he was not at all confident in any system that could put the money first.

“Bring her down to the centre” were the next words down the phone.

“But she is unconscious and covered in sick” said hubby, “I can’t just put her in a taxi”.

“We don’t do home visits” was the response.

“I don’t know the system”, said my husband, “I can’t bring her anywhere, what do I do?”

Well it might seem obvious, but my husband was panicking

“Phone an ambulance”.

Hubby did, and the ambulance came, but the co-payment fiasco didn’t end there.

The ambulance people were caring and somehow got me downstairs and into the ambulance.

We then proceeded to go past at least one gleaming private hospital, slowly down some narrow country roads, and well out of town to the nearest public hospital.

I was off loaded.

Alone with me in a room, hubby was then asked for another co-payment. “just go to the desk”. Imagine if it was your loved one, and you were asked to leave them in a crisis, and alone.

The doctor came and told him to hurry, go to the front of the queue as an emergency, as she wanted to start treatment urgently. Hubby ran.

Once back he could talk about my medical history, allergies and so on. The doctor was knowledgeable, efficient and kind. It doesn’t take long to bring me round from a dangerous situation, and I can usually get home in the NHS in around 6 to 8 hours, but even so, I was told to get a taxi probably a bit earlier than I would have needed/wanted in the UK.

Going home the taxi driver treated us to a very informed chat on how this was a trojan horse and the end of their public healthcare system. A few days before we had a taxi driver talk on TTIP and chlorinated chicken.

If anyone is tempted to think we would do it differently under the current model of defunding the NHS, just think of the brilliant success of the co-payment systems we have already.

The Care System has always been co-payments for the less poor. I will not say the rich, as demands for some contribution are made to many we would not consider that well off. The situation is dire: abuses of human rights, starvation diets, neglect; the list goes on. There are repeats of the TV programme “Waiting for God”. Not even the wealthy can ensure they are not being herded and milked for the benefit of the shareholders. It is the law.

Then there is dentistry. I was warned years ago that dentistry was the pilot for the NHS direction of travel by a totally distraught dentist, who felt his patients no longer came first, and the less well-off would be excluded. Hubby has paid £600.00 for dentures (just a couple) under the NHS system. They are not fit for purpose. Treatment is basic now, and in my town people are often seen with big gaps and rotten teeth. The old pull it out by using the door trick has even re-appeared. It is tempting to go private if you have the money, and friends have paid thousands to private dentists, though they are against the concept.

Co-payments will have the most terrible impact on the sick, disabled and poor. They will be excluded, frankly, so the worried well can have blue fitted carpets and no queuing. It will fix the NHS in the same way as taking those truly needy cohorts out and shooting them would also fix it – just it’s more acceptable/less obvious.

I have not heard a single person as a patient under the co-payment scheme who isn’t well off express that they liked it. Quite the opposite, and I work with healthcare staff and academics in the US and Australia. They know it puts their lives on the line.

Like dentistry a “reasonable” co-payment will soon start to look like quite a chunk of your money – loads more than we all first thought. And for what? This was posted on our SHA Website and I’ll repeat it here:

NHS Dental Care Faces a Severe Collapse

One of the health concerns neglected by the NHS is dentistry regardless of the fact that teeth matters as much as any other part of our body. As revealed by the British Dental Association in September 2016, the NHS had to bear a cost of £26m when around 600,000 people in a year made nugatory appointments with GPs over dental issues. Though this statistic has resulted in ridicule, yet in all honesty, it is the government, not its citizens, who should be embarrassed.

It is the NHS bills that are drawing patients away from the official government system and driving them toward GPs for their dental problems. As indicated by the BDA’s new analysis, this practice might soon outclass government financing as the main revenue source for NHS dentistry.

The NHS charges for dental services were first instituted in 1951 to bring down the demand. The BDA has named these charges as “health tax”, which veil actual trims in the service and debilitate the patients most needing care. Due to the incurred charges, about 1 of every 5 patients has deferred treatment as per the official findings.

The government funding for the NHS has been cut down by £170m since the Tories first made it to No 10, and it is hoping that patients should constitute the shortage. In 2016, dental charges were climbed by 5%, and they are anticipated to take the same hike even this year too. Considering the 16 years of time, it is assumed that majority of the NHS budget for dentistry will be financed by patients instead of the central government. But what is the use of the NHS if it is not a free service at the required time, and treatment isn’t according to one’s need but ability to pay?

Children are entitled to avail free NHS dentistry – but even they are being pulled down by the government as it is unable to meet the demand and offer enough dentists. Earlier in 2016, a letter was signed by more than 400 dentists exhorting that dental care in Britain is falling to the levels of “third world”. According to them, the NHS dental system in England is ill-equipped for the purpose. These crises are of grave nature; about 62,000 people mostly including children turn out to be at the hospital each year due to tooth decay; half of the adults haven’t been to a dentist for the past two years; and one of every seven kids hasn’t gone to a dentist since the age of eight.

People in Britain are already paying higher bills for fundamental care, and add a bigger sum of a dental budget by submitting these charges than their correlates in the devolved countries – systems of which have become less dependent on charge income throughout the recent decade. To deal with this gap, the BDA is sending information posters to more than 8,000 NHS dentists all through England to help picture patients’ feedback on the eventual fate of the charge.

When dental charges were made a part of the NHS in 1951, Nye Bevan who was the formulator of the NHS resigned from the service in protest. Today, after sixty-five years, the service is damaged by inadequate investment, exaggerated charges, and a shortage of dentists. There is a genuine need to form a government-funded NHS dentistry which wouldn’t rip off the patients. However, as of yet, we are going in the other direction of which the consequences will be borne by lower-income Britons.

Co-payments in health to me sound very much like the position refugees are suffering under this government according to the latest briefing by Asylum Matters. I have approached them to ask to reproduce the paper and recommendations, and been given the go ahead. This will follow shortly.

Finally: Imagine:

You have a heart attack in a local park. You and your partner set off in the ambulance only to discover that you must pay, and your wallets and cards are locked up at home. Precious time is lost chasing the money. Your partner is scared you will die when they are away getting the plastic.

You just gave every bit of spare funding you had for the youngest child/grandchild to access university for 3 years, and then you get cancer (or another serious and maybe longer-term condition). It is might be difficult to fund all these co-payments to your GP and specialists. It is not worth a blue carpeted half empty waiting room. Under the current defunding you won’t get that anyway. I have loads of co funding horror stories from the USA.

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Traumatic brain injuries, as the name clearly points out, are caused by a trauma to the brain. This often presents itself in the form of an external force, applied with violence at the level of the brain. Despite being protected by the sturdy cranial cavity, the brain can be easily damaged in such cases, its overall functioning being affected. Depending on the type of trauma, the injury can be closed or it can penetrate the cranial cavity. The symptoms of such traumatic injuries depend on the area of the brain that has been affected; the type of injury will also dictate the chosen course of treatment.

Brain injuries

Symptoms

The symptoms of traumatic brain injuries, as it has already been mentioned above, depend on the actual type of injury and the damaged area of the brain. Many people deal with brain injury and memory loss, especially after violent accidents. However, it is important to understand that the cognitive functioning can be affected as well; one can exhibit a wide range of other symptoms, related to the emotional, social and behavioral functions of the brain. The more severe the injury to the brain was the more diverse and intense the consequent symptoms are going to be.

Right after the actual trauma, one can lose consciousness or experience life-threatening symptoms, such as lethargy, inability to move or speak. One can experience moderate to intense headaches, blurred vision and inadequate coordination. Nausea and vomiting are frequent, as well as loss of balance, dizziness and tinnitus. If the cognitive functioning has been affected, one will have difficulties responding, speaking or concentrating.

The speech can be affected as well, with patients exhibiting slurred speech, aphasia or dysarthria. They may lose their ability to move and coordinate, especially when balance problems are associated (damage to the cerebellum). Patients who have suffered from traumatic brain injuries may exhibit personality changes, not to mention experience confusion, social behavioral problems and constant agitation.

If the intracranial pressure reaches high levels, life-threatening symptoms can appear. The patient can lose consciousness, experience an abnormally low heart rate or enter in a state of respiratory depression. In such situations, emergency intervention is necessary, in order to prevent sudden death.

Causes

The brain is protected by the tough cranial cavity and it does not become easily damaged. However, in case of trauma, things change. A violent force can cause a lot of damage to the brain, especially in case of vehicle accidents. Traumatic brain injuries are also common in those who engage in contact sports or those who have been involved in work-related accidents (constructions in particular).

Regular sports can lead to traumatic brain injuries as well, especially when violent force is involved. Other recreational activities are responsible for such health problems, especially in children. They are more fragile, as their bones are still developing and, thus, more vulnerable to such injuries. Traffic accidents, involving any kind of motor vehicle, are often responsible for traumatic brain injuries, including in the pediatric population.

Physical violence is one of the most common causes of traumatic brain injuries, not only in children but also in adults. Child abuse and domestic violence are two main causes of such injuries, leading to life-threatening complications and even death. Industrial accidents, such as the ones that occur on oil platforms, as a result of explosions or due to chemical products, are responsible for traumatic brain injuries (more commonly in men). Traumatic brain injuries are often encountered in war zones, being often caused by explosive projectiles, gun attacks and open-fire combat.

Treatment

In all traumatic brain injuries, emergency treatment is essential, in order to prevent life-threatening complications and death. Depending on the severity of the injury, the patient might need intubation (respiratory support). Emergency surgical interventions are performed, in order to reduce the intracranial pressure and avoid the excess swelling of the brain. Surgery is also recommended in case of brain hemorrhages, for the prevention of further complications.

Before administering any kind of treatment, the patient will undergo imaging investigations. This will determine what part of the brain has been affected and also guide the further treatment measures. The patient will receive analgesics or sedatives, in order to relieve the pain. Hypertonic saline solutions are administered to reduce the swelling at the level of the brain and also the electrolyte imbalances that might cause heart failure.

Fluids are administered intravenously, in order to maintain the blood pressure at a stable level. Medication, such as benzodiazepines, is administered in order to protect the brain against seizures and further damage. Craniotomy might be performed in case of excessive brain swelling or to reduce the intracranial pressure.

Once the acute phase has passed, the treatment will be concentrated on the rehabilitation of the patient. Physiotherapy is essential in the chronic phase, as it can improve the functional outcome and guarantee the best possible recovery from the trauma. Patients can also benefit from speech and language therapy, especially if they have suffered injuries to the parts of the brain responsible for speech. Other treatments include occupational therapy, psychological counseling and NeuroGum supplement.

It is important to understand that the recovery from a traumatic brain injury can spread over several years. In some cases, the recovery is not possible and the patient has to learn how to live with the remaining functioning potential. The support of family and other caregivers is essential for these patients.

Conclusion

Traumatic brain injuries can lead to permanent disabilities, affecting a person’s overall quality of life. The faster one receives treatment in the acute phase, the better the overall prognosis is going to be. Additional therapies, such as the ones mentioned above, can guarantee a faster and better recovery from the respective injury. The living environment often has to be adapted to the needs of the patient, with occupational therapy playing a very important role in the matter. Moreover, the patient has to benefit from regular counseling, in order to deal with feelings of anger, symptoms of depression and frustration in an effective manner.

AUTHOR BIO

Katleen Brown is a health, beauty and fitness writer. She loves to publish her articles on various health related websites. In her spare time, likes to do research to bring awareness.

Recognizing the unity of body, mind, and outlook, she helps empower women to tune into their innate & inner wisdom to transform their health and truly flourish.

Get in touch with her on Google+, Pinterest and Twitter.

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but they don’t relieve pressure from A&Es

The rise and fall of the NHS walk-in centre

Walk in health services of one form or another feature in many healthcare systems, including Canada and the United States. In England, the first NHS walk-in centre opened in the late 1990s but only became prominent in the late 2000’s following a policy initiative that led to the opening of around 150 new facilities.

Offering extended hours and with no requirement for patients to pre-book or register, many new centres had proved highly popular with local residents with minor illnesses and injuries such as colds, eye infections, sprains and cuts. But despite this popularity, during the last parliament around a fifth of the facilities shut their doors, with a number of others, for example in Redruth, Hereford, and on Teeside, also currently at risk.

Taking sides

Why the services should have closed in such numbers is not immediately clear: the scale of local opposition to some closures – for example in Jarrow, Worcester and Southampton – was intense. Their supporters argue they reach new groups of patients, provide easy and convenient access to care, and take pressure off other stretched NHS services.

At the same time, commissioners closing centres argue they represent a poor use of funds as many attendees have minor conditions that have little need for medical attention, and those that do could readily be treated elsewhere.  Some have cited the need to fund seven-day-a-week access to GP services as a more pressing priority.

While not the whole story, one important question in these debates is whether walk-in centres divert patients from attending busy hospital A&E departments. This may be desirable since crowding at A&E is associated with high mortality and can have knock-on effects by reducing the capacity for hospitals to carry out planned medical treatments. In addition, many attendees at A&E have low severity needs which could be safely treated outside a hospital setting. Treating these patients as emergency cases in hospitals is considerably more expensive than treating them in walk-in clinics.

Building the evidence: do walk-in centres divert patients from A&E?

Until recently there was no conclusive hard evidence – from either side of the Atlantic – either way. When surveyed, around a quarter of patients attending walk-in centres say they would otherwise have attended a hospital A&E. However, academic research using statistical methods has been unable to detect any such effect.

My research provides new evidence that goes some way to filling this gap. Combining detailed information contained in hospital records with difference-in-difference statistical techniques, I provide credible estimates of how patients’ use of A&E departments changes in response to the opening or closure of a new walk-in centre close-by.

Two main findings emerge. The first is that walk-in centres do significantly divert patients away from attending A&E. The second, however, is that relative to the number of patients attending walk in clinics the effect is small, with calculations suggesting only around five to 20 per cent of patients attending a walk-in clinic would otherwise have gone to casualty. The implication is that they only make a small dent on the overall A&E figures.

The research points to something of a dilemma for decision-makers. Easy access services such as Walk-in Centres are popular, which suggests they are valued by patients. The evidence suggests they do make a small contribution to relieving pressure at over-stretched emergency services, but with low diversion rates from A&E they may be an expensive way to do so. The cold reality of a chilly funding climate points to hard choices in allocating scarce NHS resources to best meet local demand. With this in mind, fights over the remaining centres look set to continue.

this article first appeared on LSE Business Review.

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(or You do your job and I’ll do mine).

 The notion of referred pain, where the symptoms of a health problem manifest themselves in a part of the body that is not itself the cause of the suffering, is well known. The care system increasingly suffers the organisational equivalent but those managing it- unlike most doctors attending on patients – seem incapable of adequate diagnosis and effective treatment.

The author once worked with a “radical” surgeon of whom it was said that he  never made a three inch incision if a two foot one was possible. One only sought his skills when all else had failed.

The care system has too much referred pain within it. Worse, politicians and managers continue to be distracted by where the pain appears, rather than attending to the root causes. A radical approach to treatment is called for.

A few examples will suffice.

The ambulance service regularly fails to meet its performance targets. (Unmanaged) demands have risen. Front line vehicles, languishing outside A&E because that department is overflowing are pressed into service as overflow treatment bays. Welsh Ambulance Services NHS Trust performance targets do not reflect that assumed role. Neither are resources made good to ensure it still reaches the ill and injured in time.

A & E departments are overflowing partly because they never close and are the easy recipients of people who do not require its high powered skills and  partly because they struggle to admit diagnosed patients to appropriate wards,  or divert them elsewhere.

Wards are full, partly because of rising demand, but also because we have been slow to re-engineer the total care system. We do not provide a complementary 24 hour emergency social care system and primary care is not appropriately keyed into the total care system when care deemed urgent   by the public is sought.

What to do? We could follow the buccaneering approach of my surgeon friend and deliberately expose where the pain in the system is in order to fix it.

For example:

  • ambulances arriving at A & E, would hand over and leave.
  •  A & E departments would only treat those needing its skills and would move diagnosed patient onto wards if a stay was needed, or would divert them to a 24 hour community based  care centre that would take over their care.
  • Wards would immediately move patients no longer needing their skills to settings and agencies better placed, or legally required, to meet their needs

The last change probably requires home adaptations and home care packages to be managed differently, and for residential / nursing home placements to be more available. In short, a round-the-clock social care service designed to “take the pain” could be one result of meeting care needs in a more timely and appropriate way..

Re-designing the care system as a whole to ensure that people rarely languish in the wrong bit of it would flow from knowing where the pain really is.

The sooner we reach a stage where the pain in the system is traced to its proper source – and then addressed – the better.

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Dear Andy
I have read your new Health Manifesto which contains some significant steps forward in our health care but I am deeply concerned that I cannot find how our Manifesto redresses the attack on our District hospital A&E and Maternity Units. As a result there is no equity in provision of acute care, especially in the rural areas.
As Chair of SOS Grantham Hospital and Labour County Councillor for Grantham South (and current District councillor for Grantham St Anne’s Ward) I can advise that we are about to lose what remaining A&E we have.
The Hospital Trust (ULHT) are strapped for funds and are reviewing all acute care in the County. They propose a new Ambulatory Care Unit goes in, that is little more than a minor injuries unit and will not meet the acute medical needs of the population of people living in the East Midlands A1 corridor.
Newark Hospital lost its A&E and now has a Minor Injuries Unit. At the time the cut was justified on the grounds Grantham could provide A&E services. This area has become a vacuum as far as A&E provision is concerned with acute services being ‘sucked’ away into the cities, despite the presence (and therefore associated high risks) of main rail routes, poor internal mainly single carriage A roads, the A1 and a mix of industry including agricultural, oil and mineral extraction. We also have a significantly increasing elderly population as people leave the South East and move up to Lincolnshire and extensive coastal area.
I recall drawing this issue to your attention at your Workshop in Nottingham and understood you were going to address the loss of A&E Units which progressed under our former Government but I cannot see how the current Manifesto achieves this important step.
The whole of Lincolnshire is to see a centralisation of its acute medical care. This is simply unacceptable when we consider it is the second largest county in the country and one of the poorest. It is very simple. If we allow this to happen then the free access to the NHS services we are committed to for all will not be delivered. Only those with a car will seek emergency medical attention unless in a critical condition. Our ambulance crews are already overstretched regularly taking up to an hour to respond (with the added travel time of an hour and more to an A&E Unit).
The Golden Hour, once lauded as vital, especially in stroke situations, will be a thing of a the past for the majority of residents of this county.
We have campaigned against cuts to our services ( a 25k petition went to Downing St) over historic threats (under your watch). The Labour Government did listen and whilst under Labour there were some reductions in service the A&E and Maternity Unit remained.
Under the Tories despite a 7.7k signature petition objecting to the threats to our maternity unit being closed (so now 1000 mums to be a year are forced to travel from the Grantham area in labour) we lost a super Maternity Unit.
Now our A&E unit is facing a death knell in the guise of an Ambulatory Care Unit. Despite thousands of petition signatures the United Lincolnshire Hospital Trust and SW Lincs Clinical Commissioning Group have paid lip service to the views of the  public.
Again, on this front our proposals to sit round a table with the hospital managers seem promising but I doubt will make any difference unless there are real teeth to the proposals that ‘require’ the administrators to take the views of the public into account AND to demonstrate how their views have been reflected in the outcome of any consultation through changes to the proposals. (I am a Business Improvement Consultant). As a councillor I have to send a questionnaire to all households affected by a resident parking scheme and have a majority in favour for changes to go ahead yet the hospital trusts can withdraw vital healthcare provision with no such level of public engagement. This should be addressed.
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Florence Cunningham trolley.jpg

We know that Sir Bruce Keogh is very keen on ‘wearable apps’ – little apps you can download onto your smartphone to improve your health. NHS England seem enthusiastic about getting senior staff in the NHS to dream up apps to improve patient care. Part of this, presumably, is wishing to make the NHS profitable like Apple; but part of it is genuinely driven by a wish for technology at low or no cost to improve vastly someone’s quality of life.

Apple in their recent launch proudly showed off a new app which could act as a mini research lab, taking samples of your speed of finger tapping for example. It boasted that you could contribute to a giant ‘research lab’, and the multinational corporation showcased people from prestigious American hospitals with impressive titles.

The philosophy behind ‘targets’ in the NHS, latterly being rebranded as ‘ambitions’ in the innocent hope of diffusing their toxicity, was to ensure a minimum level of performance. It is a quick fix way for a politician or hospital manager to say that something is being done. Of course, to total embarrassment of everyone is when targets are regularly missed.

In terms of ‘performance management’, it is hard to see how repeated missing of a target can be good for staff morale. One would think it at first is bad for morale, but, then as repeated missing of the target becomes the new baseline, it can theoretically implant a culture of ‘it cannot get any worse’. This is of course is bad for the organisational culture of any institute, let alone which is supposed to be driven by patient safety. It is this culture, together with a sense of ‘too something to fail’, which presumably kept Mid Staffs and Morecambe Bay in their bad times.

You would not typically dream of rating your experience of a meal in a restaurant by how fast it took you to get your food, unless it was a very protracted way, rather than the quality of the actual meal. You should not wish your food to be rushed to your plate if half of it was blatantly undercooked, and not fit for consumption. You should not be particularly inspired if the restaurant were clearly understaffed, relative to the demand of customers, such that it took you a long time to get a waiter’s attention.

Managers refer to this as the ‘visibility’ of ‘operational management’. A restaurant is a good example, compared to a NHS A&E department, not because of the similarity of the service it provides; but because it is a high visibility service. In other words, it is pretty clear to the ‘end user’ when the organisation of the operation is more chaotic than competent.

In judging how long it takes for an Ambulance crew to arrive at a medical scene, there are clearly unsafe time windows, particularly for acute medical emergencies such as chest pain or anaphylactic shock. But there is a danger if something is then misdiagnosed, sending a patient on completely the wrong care pathway.

What happens at 3 hrs 45 mins of the ‘four hour wait’ target is similarly interesting. A four-hour target in emergency departments was introduced by the Department of Health for National Health Service acute hospitals in England. Setting a target that, by 2004, at least 98% of patients attending an A&E department must be seen, treated, admitted or discharged in under four hours. The target was revised by the Department of Health to 95% in June 2010.

If an A&E team have a few missing results from investigations they’ve ordered in assessing a patient, say a blood test has not even been ordered or the result has not come back from the lab, a clinician (or even potentially a non-clinical flow manager) might take a decision to admit the patient to hospital, or to discharge, to avoid breaking the four hour wait. This decision can therefore be primarily managerial.

A disparity of information between patient and doctor, “information asymmetry”, can mean that it will be clear to the doctor when this 3 hr 45 mins time has been reached (but not clear to the patient). Anyone who has ever been a a patient in A&E, or even worked there, will testify what a stressful working environment it is, taking on a timeless feeling to it.

But a smartapp on your smartphone would be able to tell you this information as you ‘count down’ your experience in A&E. You see, more helpful to you as a patient, and ultimately the NHS, is whether your experience in A&E has been a good one from the perspectives of patient safety and patient experience.

A simple checklist on a questionnaire would be triggered at four hours so that you could ‘rate’ which staff you had seen, whether you had been seen by a senior clinician, whether your investigations had been ordered, whether your test results had arrived, at the four hour mark. If so many people are repeatedly missing the four hour target, there would be plenty of respondents to the survey. You could of course be asked to suggest what you think your working diagnosis might be.

This information could then be downloaded by your GP, the hospital and NHS England, so that they get a feel for your experience in A&E in a way that would be beneficial for rating patient safety and patient experience. Such raw data would be likely to be much more helpful than filling a questionnaire for the ‘Friends and Family Test’ weeks after an event. Such information could be available in real time such that hospitals could be aware if their services in reality were understaffed compared to demand.

The smartphone app might cost the NHS a minimum amount, if it could be downloaded by the NHS patient for 99p. You would not need the NHS to pay vast amounts of money to the types of IT companies you see at Olympia every year at these NHS ‘Expos’.

Such an innovation is clearly disruptive. Disruptive innovation, a term introduced by Prof Clayton Christensen at Harvard, describes “a process by which a product or service takes root initially in simple applications at the bottom of a market and then relentlessly moves up market, eventually displacing established competitors.”

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It’s been a very difficult week for the NHS with hospitals across the country struggling to deal with significant pressures on their services.  While the political spotlight which comes with the start of an Election year hasn’t helped, talking to colleagues in the acute sector I am clear those pressures are very genuine and I am full of admiration with the work which they (both  front line staff and managers) have been doing to address them.  Furthermore as Nigel Edwards, Chief Executive of the Nuffield Trust, stressed in his blog on the issue while the problems are serious they are not catastrophic and performance is still good compared to historical and internal comparison.

As most informed commentators have flagged up what is happening is not straightforward.  It is the winter with the usual seasonal upturn in illness and a corresponding upturn in demand at the front door.  Yet by all accounts that increase in demand is not unprecedented and it appears that A&E activity was higher in the summer.

Delayed discharged is also an issue.  Some of this, unsurprisingly, has been due to pressure on social care budgets but a greater proportion of delays have been caused by issues around the co-ordination of NHS care.

Linked to this the impact of a greater number of frail elderly and often isolated people in the community means there are more people with more complex needs who are at greater risk of needing hospital care and for whom the process of returning them safely to the community can be more complex and take longer.

Finally there is the impression of what is a complex and stressed system operating close to capacity which becomes increasingly less able to absorb the pressure of significant if in some ways predictable demand.

I do not claim to the have the answers to the woes of A&E but the recent events have reminded me of issues which arose when I worked in this area in my time at NHS Direct about how the urgent care system  operates and how we want to support the public in using it.  It also highlights key fault lines in the way in which we organise care and support, which while undoubtedly well recognised, need to be addressed with urgency.

So on that basis I have a list of 5 things which we should use the present challenges to prompt us to make sure are different about access to urgent care in the future.

First, in my view, there are strong arguments for a primary care led front door to the NHS round the clock and round the year.  As they are in hours, primary care clinicians are best placed to make a rapid initial assessment of the seriousness  of someone’s condition and whether to use the phrase of a clinician I worked with at NHS Direct, they are “big sick” or “little sick”.  In the small number of cases where there are good reasons for doubt there should be the scope for rapid referral for further assessment by hospital specialists.  We have been talking about this kind of changes in urgent care for years.  Now is the time to make it happen.

Second we need to ensure that when patients are at risk of going into hospital their medical records and pre-existing care plans are able to follow them.  History and the knowledge of what support may already be in place for individuals makes a crucial difference in many of the cases where admission could be avoided.  As well as struggling with the technological solutions to enable this we still appear to be tying ourselves in knots in terms of information governance.  We should rapidly get to a position, which I am sure the vast majority of patients would support, that with appropriate but simple safeguards, information about a patient is able to follow them around the health and social care system.

Thirdly we can longer afford a system where there is an institutional division between the delivery and, very crucially, funding of health and social care.  With the scale of pressure on local authority budgets it in the last couple of years there can be no surprise that there are difficulties in discharging frail elderly patients from hospital who need social care support.  Many commentators, most recently the excellent Barker Commission, have made the logical, moral and economic case for bringing these systems together.  Our next Government must grasp the nettle and make a reality of this in the next Parliament.

My fourth point is to recognise that A&E has in too many cases become a default point of access for a range of groups, for instance people with mental health problems in crisis, who should have access to a more appropriate response to their specific needs.  Just before Christmas research by Paul Burstow MP suggested that in 2014 the number of people visiting A&E   with mental health emergency could have topped a million, a threefold increase from 2002.  This vividly highlights the impact of growing demand on mental health services during the period of austerity and the crucial need for investment to deliver parity of esteem.

My fifth point is the need to think about the psychological as well as physical aspects of urgent care.  Many of the factors which drive the need to seek urgent help, which exacerbate symptoms or which erode the capability of family carers to cope are ground in psychological factors and in particular the difficulty of containing anxiety.  Such factors can also impact on staff working in highly stressed and unforgiving systems.  The development of and training in psychologically informed practice has a significant role to play in helping us design a holistic urgent care system which is fit for purpose.

That leads me onto the issue of the conversation we want to have with the public about how they use A&E.  We need to recognise that there are variety of reasons why people come to A&E but in the vast majority of cases they are legitimate.  For many, unexpected ill health is a source of significant anxiety.  In some cases the difference between “big sick” and “little sick” is obvious but in many cases it isn’t.  The consequences of getting it wrong, especially if you are making that judgement on behalf of your child or an elderly relative.  It was one of the strengths of NHS Direct that it accepted that anxiety on a non-judgemental basis and provided support and reassurance which might help patients manage symptoms without needing urgent care.  If we want to support patients to take self-care seriously we must invest in those sources of information and reassurance which empower them to do so not spend money on advertising campaigns which tell them they might be stupid enough to think that A&E might be there “to kiss it better”.

So for this week the right response to the difficulties in A&E is to praise the efforts of staff across health and social care that have gone the extra mile to ensure care is available for those who need it.  However it is doesn’t have to be like this and, together, we need to accept the challenge to change the system to make sure it isn’t.

Paul Jenkins is the Chief Executive of the Tavistock and Portman NHS Foundation Trust. This article is reproduced by his kind permission from his personal blog.

 

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SOME IMPLICATIONS FOR WELSH NHS

In April 2013 the  First Minister, Carwyn Jones, established a commission chaired by Sir Paul Williams to independently review all aspects of Wales’ public services to see how they are currently working and how they can be improved in the future. On Monday, January 20th Sir Paul, who was formerly the Chief Executive of NHS Cymru, published his Commission’s report.

It is a very important document which plans to fashion public services in Wales for the next generation. Due to its recent 2009 structural reform which ended the “internal market in Wales  the Commission was asked to exempt the NHS from direct recommendations. Nonetheless there are implications for the NHS in a number of its key  recommendations.

Public Services in Wales

The Commission’s overall view is that public services in Wales have islands of good performance. There is therefore an urgent need for these to be extended to become the norm.

Welsh public services need greater ambition and greatly improved performance across the whole sector. We need to raise the bar to higher than being “best in Wales”. These problems run much deeper than what arises from the complexities and difficulties created by the myriad of existing structures and organisational boundaries. Transformative improvement is needed, not least because   projections anticipate that Welsh public services’ resource will decline by up to £4-5bn for the next decade or so.

This reduction will have a major effect on the role of the state and public services in delivering “the common good”  both in terms of practical service delivery and in being an important dividing line in policy terms.

The Report accepts that public services in Wales will not be subject to the invisible hand of  commercial and competition challenge. Consequently the  visible hand of public accountability and scrutiny must fill this gap as a means of driving performance. However this is done  very inadequately in Wales at the moment.

Public engagement is often seen as a bureaucratic necessity which, as the Report agrees, almost invariably changes nothing. This perception is particularly true of the NHS. Scrutiny is seen as threatening and usually evokes a negative and defensive response.

The Report recommends a move to a total integration of health and local government services in Powys on the basis that this large rural area has only community based health care with hospital services being delivered from outside its border. While earlier moves in this direction did not reach fruition, this integration should be welcomed as an important innovation which could provide wider lessons for NHS areas that do have a hospital network.

Community Health Councils (CHCs) are recommended to continue with an enhanced advocacy role but probably with a diminished inspection role. CHCs spend a lot of time and effort on their inspection programme but it is not clear that it adds anything to the inspection programmes carried out by other regulators.  However the Commission does not acknowledge that while CHCs have been an important part of the NHS landscape in Wales for decades, they  have seriously underperformed in terms of being an effective patients’ voice.

They do come to the fore when major service re-configuration is taking place but their day to day work is very low key and is almost unnoticed by the public. The purpose and role of CHCs is valuable but we need a better way of giving effect to it. One option is that this might be achieved by CHC functions being linked to more organically to mainstream democratic structures and processes.

This might be a role for an enhanced CHC but also it could also be a role of a democratic body such as the local authority perhaps enhanced with third sector and other public interest groups. We could also consider an enhanced role for CHCs in social services scrutiny though there could be an overlap with local government scrutiny which would be an unwelcome duplication. Again this is an argument for an integrated public scrutiny system incorporating local government.

A fundamental weakness in proposing democratic scrutiny of the NHS by local government is that its current scrutiny of its own services is not an exemplar of good practice. The Williams Commission makes clear that local government scrutiny must see massive improvement and the proposal to extend local government’s scrutiny role in the NHS should be seen in this context.

The Report correctly is critical of the adequacy of the current performance of Local Health Board non-exec board members. They are appointed for their technocratic expertise but this creates a major gap in local democratic accountability. A balance  has to be drawn between local accountability and professional expertise in carrying out board duties but the Report suggests that the current balance is not right.  This seems to be correct.

The present LHB structure ,which is the outcome of the abolition of the internal market in Wales, is correct but it needs to improve its governance performance. Too often LHB boards have the mind-set and behave like a former acute hospital trust board ( with all their weaknesses). They have not been able to incorporate the good community links that the earlier LHB boards had created, accepting that the former LHB boards were too big and unwieldy. As well they are still struggling to give effective priority to primary and community health care.

Interestingly the Report highlighted the apparent paradox that Board members are corporately responsible for their own decision making and still have, potentially, a self-scrutiny role. It seems to suggest that the scrutiny role is not compatible with the corporate decision role. The unstated but obvious implication of that is that there is a need for external scrutiny and challenge. If this external scrutiny was to have some democratic basis it might help to fill the accountability deficit that the Commission identified.

The Report did flirt with the idea of democratically elected LHB non-executives but it did not explore the idea in any depth. Is this something that the SHA might wish to consider though it is likely that LHB elections would resemble the Police Commissioner elections which have provided a somewhat limited popular mandate?

The Report was very clear in  rejecting the transfer of adult social services to the NHS. On balance  their conclusions are correct even if the decision is fairly finely balanced. The Report says, as an alternative, that there are sufficient mechanisms in place to allow joint, integrated social services commissioning  and delivery. This is the case as there has been an insufficient use of these mechanisms — a symptom of the overall sluggish public service performance in Wales.

The Report recommends closer links between the Ambulance and Fire Service. Again this is something that should be welcomed. The Fire and Ambulance service is a joint service in many countries like France and in parts of the USA. There are obvious synergies between the services though there are massive operational and cultural differences at the moment.

Interestingly the Report is very positive about many aspects of the performance of the Fire & Rescue Service. This stands in contrast the on-going challenges facing the ambulance service. An immediate priority must be to improve the performance of the ambulance service. Nonetheless a clear signal as to the direction of travel should be given to both emergency response organisations with a medium objective of much closer integration of the two services. A key early issue in this context is the station network of both services. The Welsh Government should require that no decision on station network of either service is taken in isolation and should consider the implications for its partner blue light organisation.

The Welsh ambulance service has been to the fore in enhancing the skills of its paramedic staff to cover conditions that are not immediate life threatening conditions. These enhanced skills do overlap with some GP out of hours work. At the moment the ambulance service is seen as part of hospital out-reach services. Consequently they are obliged to transfer their patients to Accident & Emergency Departments if they are not being brought to the hospital for admission. Some flexibility in these arrangements could allow the ambulance service to also interface with  primary care  and bring patients to that service if clinically appropriate rather than mechanically bringing them to A & E Departments.

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