Wednesday 3 April 2013

We Need to Talk About The Ambulance Service

"An emergency service in crisis?"

Yesterday, I read a brilliantly written blog by @NathanConstable entitled We Need to Talk About The Ambulance Service. If you haven't read it yet, please do so now, otherwise this post won't make much sense! He speaks about a lot of issues that surround the ambulance services in general and what knock on effects that has on the police. Rather than leave a long rambling comment providing my thoughts on things, I thought it would be better explained in a post of my own.

I didn't take anything that @NathanConstable wrote as a dig. It is a discussion that needs to happen, but realistically, it needs to be happening between senior figures in the police, the ambulance service, the NHS and the government. I just wish they'd listen to what we are all saying, where we are not ruled by the politics of a situation! Like Nathan says, for all the inter-service teasing and banter that goes on (and before you ask, my call sign is Whiskey Delta 4-0. Oh, and fireman, hold these fluids, good dog!) there is a mutual respect and a fantastic front line working relationship between all emergency services. We do many jobs with the fire service, some are the most traumatic of jobs we will every see. I do have a huge amount of respect for the job they do. The relationship between ambulance and police is a stronger bond, born from the huge amounts of jobs that we do together. As detailed in 'A Special Relationship' I, along with the rest of the profession, hold the police in the highest regard.

My first thoughts when I read 'The Ambulance Service is broken' was agreement. I nodded my head as I thought about what was wrong with the ambulance service. However, the more I read on, I came to a very different conclusion. Despite its failings with the relatively small things we moan about on a day to day basis (missing kit, hours, breaks, working conditions, pay bands etc), on the whole, I think the Ambulance Service is far from broken and I'll do my best to explain why.

I can't argue with the fact that police are having to wait longer and longer for us. They do. Nathan gave 4 examples of waits he's encountered, but I'm sure he could list another 20 or so without any trouble. And that is probably only the last month or so! I also wouldn't struggle to list the police jobs that I have been cancelled on! THAT frustrates me. I know if I ask for the police, if there is a unit available, they will come. Far too often, we are cancelled for a 'higher priority' knowing full well that police will have to start the wait again. The problem however, I don't believe is caused by the ambulance service alone. It's caused by triage, call rate and hospitals. I'm not saying the ambulance service is totally blameless but it does feel from a front line perspective, that we are being pulled from all sorts of different places, meaning we can no longer function as an emergency ambulance service. Whilst police wait and wait and wait for us, on thing is for sure. Someone else is waiting to!

So, hospitals. Nathan documented seeing 5 ambulances sat at the hospital due to lack of capacity. Well from experience, I'd say he caught them on a good night! Only last week I was stuck at a hospital with 13 waiting ambulances due to a lack of capacity inside. There were patients who could walk and who eventually went to the waiting room but the nurse in charge wouldn't take the hand over, so therefor we couldn't leave. This BBC article - documents the problem well. No ambulance service could cope with all 17 of their emergency vehicles being stuck at 1 hospital. Due to huge fines for going on divert, hospitals don't. They just make us wait in corridors. Until the patient is off our bed, they don't become the hospitals patient so departments are in no rush to take the handovers, off a huge queue of ambulances. What's the result? The police are still waiting for an ambulance. It isn't just the police though. Whilst they are waiting, so are dozens of other people who have phoned 999. Is the ambulance service to blame for these delays?

Call rate is another big problem. Year on year the call rate is increasing at an alarming rate. My service alone received over 1.7 million calls last year. Calls are coming not only from the public, but also from GPs, hospitals transfers, the police, the fire service and now the new 111 service, which has seen a huge spike in the need for resources. With government cuts to the budget, there simply isn't the money to replace the 25+ staff who are leaving each month. The crews on the ground are working harder and harder. We are being forced (with financial penalty) to turn jobs around quicker and quicker to try and match demand for the service. Our control room has just started a pilot, of refusing to send ambulances to some calls, in an attempt to ease the pressure. We simply don't have the budget or the resources that the police and fire service have and us such, the service is struggling to cope. 

Despite the calls volume and despite the delays at hospital, there will always be the eternal problem of triage. How does one call get priority over another? Why are the police told an ambulance is on route and then one never materialises? Triage! Calls are categorised, then re-catagorised. Crews are sent, then cancelled for a higher priority, then cancelled for another higher priority, as 200+ calls an hour continue to roll in! The issue is priority symptoms and the police are victims of their own common sense.

When the police call and ask for ambulance back up they say exactly what they see and exactly what is happening and therfore a '20 something year old male with a head injury' which has had a dressing put on it by a police first aider will get trumped every time by a 35 year old female with a cough. Why? Because the general public know what buzz words to use. A cough is cough, but when they call, they say they have difficulty in breathing and when asked if they have chest pain, they say yes, because there is pain in their chest from coughing. Now, you have a situation where an ambulance and a car are sent to a '35 year old female, DIB and Chest pain' because those are the priority symptoms she flagged up. The same problem happens with 111. A simple headache becomes meningitis, prickly heat become anaphylaxis and so on. It is a world wide problem. People lie to get what they want and no ambulance service will ever risk NOT sending an emergency response to a DIB or Chest pain. That is, if all their ambulances are not sat at a hospital or busy doing critical transfers and the plethora of other things we are being called to. And who has to wait? Whoever told the truth!

Again, I don't think this is the failing of a particular service, triage is there to get resources to the highest priority of calls the quickest. You rarely hear of there being absolutely no resource to send to a cardiac arrest. All it means is someone else is left waiting. The AMPDS triage system that is used, is modified world wide and if used correctly works well. Unfortunately, until a cure is found for liars, time wasters and hypochondriacs triage will remain an issue. 

One thing that Nathan spoke at length about was the amount of calls they attend to back us up. It's true. They do, and this is a failing of the service and of individuals. I have worked with a number of people who see the words 'mental health' and call the police. If the word 'assault' appears, the police are called and there is a case to answer for us never going to scene until police are there. Records of flagged addresses are woefully out of date, hence why I've been sent to an 80 year old with chest pain accompanied with armed police and ballistic vest! This needs to change but requesting back up at the first sign of trouble is often too late! As I detailed in 'Please Sir, Can I Have Some More' we are not even remotely equipped to deal with violence against us. The half day conflict management course really doesn't cut it. That job also highlighted how the police are stretched so thin that they also 'have no units to send'. Is the police service broken? I'd say no, but I would say, like us, they also struggle to deal with the demand placed on them by all and sundry! The public, the fire service, the ambulance service, mental health services and hospitals all call on the police and there will always be someone, somewhere, who is left waiting. And who is that? Probably the low priority who told the truth, the whole truth and nothing but the truth!

Finally, there is the issue of the merger! Now, this was like a red flag to a bull and the only part of the blog I 100% disagreed with. I've made no secret of my distain for this idea in 'Fire Brigade: Hands off our service' and 'Unhappy Trumpton.....Bless!' . It is something that the fire service is keen on, but they are keen on taking on us rather than the other way round. If the fire brigade became part of our HART team then perhaps that would work but that would never happen. They are far too powerful an organisation to lose their identity for starters. You only have to look at the obscene budget they manage to repeatedly procure to see this! £50,000 on a coffee machine at HQ says it all! They have been after part of the ambulance service for some time, namely, to justify their resources. Their cuts under this government regime have been minimal in comparison to ours and the police. I can see no benefit in merging the police and fire and just as little in merging ambulance and fire. I does work across the pond but a) that's how it has always been so the infrastructure is there and b) with the ability to charge for all emergency calls, you can pay for the resources to cover call volume! The more calls, the more money. Over here, with the ambulance service deeply embedded within the NHS and with the lack of emergency service status, I can't see it ever happening. 

This has been a great opportunity to discuss the failings and trials this countries emergency services are facing and I'd like to thank Nathan Constable for writing such a great post. I don't see them as failings. They merely highlight the detrimental effect this government regime is having. I don't think the ambulance service or the police service in this country are broken. Not by a long shot. I  think they both perform admirably and perform over and above what their resources, diminishing budgets and demoralised work forces probably should. And THAT is a testament to individuals who turn up when someone phones 999. It's an honour to be part of the team.


  1. Thank goodness for common sense! I have the highest regard for NC but it made really angry to hear him say the police are having to do your job. He could no more do it than you could do his. I'm sick of hearing how superior the police are to every other emergency service. It's not true and never will be! We need all of you in all your difference guises, complementing each other, not criticising.

    1. Thank you! I don't think he was saying that they are doing our job, more that they are left having to improvise due to our delays. He wasn't saying they are equipped or able to do our job, but like in any situation, if there service you need is not forthcoming you have to improvise, adapt and overcome! Regarding your last point, I genuinely think we do compliment each other like you say. I don't think they see themselves as superior, after all, we do completely different jobs, that simply overlap. I'm sure Nathan would hate think that his blog came over as sounding superior. I personally don't think it did. We can all only write and comment on experiences we have faced. He can't comment on the frustrations of having to wait for police like I can't write about the fear of waiting for an ambulance! We are all in this together and he has been very welcoming of my reply post. Thanks for the comment and your support! It is appreciated!

  2. As an ordinary member of the public what I am hearing from both blogs is that the problems are not with the services themselves but with the management and organization especially of situations where there 2 services meet.

    I mean as far as the lying and knowing of buzz words goes we can all dream of and describe improving society so it doesnt happen but being realistic that is the longest of long term dreams. So I would suggest that the other option is to accept it and work out how to minimize its impact which it seems to me the management and organization are not doing. Why cant lying be added to the triage assessment?

    For instance buzz words DIB and chest pain. Why not do something to kind of downgrade these from buzz to prompt - for example if the person claiming DIB is the one making the call and they are having no difficulty talking then its a fairly sure bet they are lying - I have asthma and even a mild attack will mean I am not talking. With chest pain there are types - I gather the pain is totally different between chest infection/cough/heart attack (people I know with heart conditions certainly know the difference even if I get worried lol) so why not explore the description further. There will be others.

    I am not for a minute suggesting that the phone operators stop prioritizing these things off the cuff with no investigation but how about some investigation? Say where call handlers are asked to note one piece of extra information and based on that note whether they would downgrade the priority while not actually doing so - then after 6 or 12 months compare their notes with what the crews actually found. Says its the DIB talking thing - if after 12 months it is found that in every case where the call handler noted they would downgrade the priority because DIB was talking no problem the crew found that the patient was indeed a lower priority then update the triage thing. (I may be teaching grandmother to suck eggs here and such things may already happen apologies if it is so) Yes the public would discover that and start getting other people to phone but the management would have to be responsive. I know you talk about the dangers of judging and try not to do it but I would suggest on some things that judgement should be considered for investigation - if 100% of a certain judgement across lots of staff and thousands of patients turns out accurate then introduce that to the triage system.

    As for hospital handovers .... no dont worry not another essay. I am afraid that totally relies on senior management waking up and finding ways to solve - like a maximum ambulance hand over time with the dreaded penalties for taking too long

    Apologies for the essay - I am afraid the blogs got me thinking (and you dont want to know what I deleted)

  3. At he moment we do ask 'do they have any difficulty speaking between breaths'and as a calltaker answer this question if it is a first party caller

  4. I was told that the reason the midwives at hospital thought I wasn't in labour when I phoned was that I was 'too calm'. This was until they saw me. Hey, what can I say, I am a calm person!

    would dispute that 'the general public' know about DIB - but some people do. I don't know the answer. I do know that getting rid of fines and waiting time targets in A and E would help. If you have a cut finger, who cares how long you wait? Whereas if your aorta is dissected, you can't wait a minute, so waiting time targets are complete shit.

    The problem is, politicians keep trying to meddle with and control the NHS. They need to butt out, and leave it to managers - who should be clinicians, not career managers who know nothing about health.

    Oh, and Ella, one thing you can say about the fire service... - they have a bloody good union. ;-)

    1. You really would be amazed the amount of people who do know about DIB. At least the ones that call ambulances do anyway!

      Do they have a good union. Everything they campaigned to protect they lost out on. Their long shifts are going, their wages are still less than ours and despite protests they are quite rightly closing down various fire stations! Doesn't seem great to me!

    2. I had similar when I broke my leg - the paramedics came in and one had to go back to the vehicle to get the splint lol - I am in the weird position of fibromyalgia and stupidly high pain tolerance so apart from my stupidly distorted ankle there was little indication of anything wrong because I wasnt hurting much more than normal.

  5. Round here, the crews log the time they get to the ED, and if the hospital takes longer than (I think) 15 minutes for the patient to be handed over they can get charged per minute after that.
    Queues at that hospital don't seem to be as long as others...

  6. Ironic that the pic you've put in of all the ambulances outside UHW A&E and that's actually a hospital where ambulances can offload straight away and A&E staff assume responsibility for the corridor queue. 1 possible solution?!

  7. The biggest problem with the triage tool seems to be that most of the information appears to be gathered by leading questions. I appreciate that patients and family members need guidance when under pressure however a lot of the call seems to be "does the pt have dib,chest pain, blood loss etc?". Recently I was off duty with my family when a child started fitting so I offered assistance, I was incredibly frustrating listening to the 999 call. Plus as Ella says the "regulars" will always know how to work the system.

  8. I fully understand about the police waiting for the LAS , but last week I spent almost am hour and a half at the side of the road after being called by the police for a collapsed male in the street only to be told at the end of it that then had already dealt with it, we were not delayed on gettin to scene and while we were waiting for the police there were several GB going out

  9. Excellent post. I don't necessarily agree with all of Nathan's post but he does raise some valuable points. However you have answered a lot of them. There is nothing worse than waiting for Ambo to turn up, only to be told that they will be a bit longer. Now I know the reason why. "Service users" who know how to play the system and say the right things to get a response. We get the same thing when Chardonnay calls Chelsea a slag on Faceache. Somehow it becomes harassment or anti-social behaviour and illicits a police response. And if its because Chardonnay is black/white/pink with purple spots, the response is almost immediate! You are absolutely right about a special bond between the police and the second emergency service. It's funny how we both seem relieved when the other turns up! Your databases definetly need updating for addresses. I must say thought that one thing that annoys me is when we are sent to assist ambulance gaining entry to a premises where Mrs Miggins has fallen and can't get to the door. I have found that Ambulance "in attendance" doesn't actually mean that they are there. I do wish that your controllers would wait until you arrive and pass an update that you cannot get in rather than contact us telling us that this is the case, only for me to turn up (twice now grrrr) to find that ambo haven't arrived yet and that the back door is unlocked! You will always get a wave and a smile from me (Trumpton take note). As for Trumpton taking over, they couldn't put up with the extra work ;)


I love comments! All bloggers do! If you have something to say, agree or disagree I would love to hear it! I will reply to all! (or try my very best!) If however, you're a troll, save your breath!

Due to an increase in spam I moderate comments but ALL genuine comments will be posted. See above exclusions!