Wednesday 8 October 2014

A Bad Habit

"50 year old female, back pain, #111"

I pulled up outside the house, grabbed my bags and a full PRF and headed in. On the car, we use mini-PRFs as we normally hand over to the crew. If we leave someone at home then a full size PRF is completed enabling you to go into further detail. This patient was not going to be going to hospital! A one week history of back pain in the middle of the night was not an emergency, nor did it need to waste the time of a busy A & E, a heaving walk in centre or a snowed under out of hours GP. 

I listened careful to every word about the back pain and followed up with a long list of probing questions. Sometimes it only requires a few, others it requires an very in depth history. This was somewhere in the middle. I assessed her pain, her mobility and decided she, as predicted, had non-traumatic back pain with no relation to the heart. I did an ECG, and all her observations. All were absolutely fine. She hadn't taken pain killers or anti-inflamatories so I gave her both and left her with advice for now and future. She was a perfectly nice woman, polite, offered me coffee and some food so I have no complaints. I declined all the offers, said goodnight and headed back into the darkness. 

I have ranted at length before about people not using the ambulance service appropriately. In fact, its not just about the use of the ambulance service, it's about the use of NHS services as a whole. Mis-use of GPs, A & E and NHS111 all lead to a strain being placed on an already stretched service, but why?! Why do people do this?! I refuse to believe it is just about education and that people didn't know what they were really doing when they called 999.  They know exactly what they are doing! 

They know when the GP receptionist says 'is this an emergency?' the patients (myself included in the past) will say 'yes' invariably! Why? Because they will get an appointment. They also know if they mention discomfort in their chest when phoning 999, they will get an ambulance quicker. The fact is, the way patient uses the NHS is relative to their previous experience. If someone can never get a GP appointment, they'll lie to get one. If someone had to wait 4 hours for an ambulance, they'll lie to get one quicker. If someone had a bad experience at an A & E, they'll tell you they are under a different hospital to avoid going there. Previous experience will always mould future behaviour, it's basic human instinct. 

The problem is, like I have discussed before, experience is so varied depending on postcode and area,  and will also be heavily swayed by the quality of staff who deals with you. For example, say I've not been feeling right for a few days. I would phone my GP, it's not an emergency so I'm offered an appointment in 10 days time. That's no help really but I take it. 10 days later I may or may not be feeling better and I go to my appointment. The GP decides I need bloods. He gives me a letter, I then I have to go to  blood clinic which is miles away. Anyway, I go. I take a ticket, wait ages in line, get my bloods and go home. I'll never get those results unless something is wrong. That said, it could be an anxious wait. All in all, after a phone call, a 10 day wait, a trip to another hospital for bloods and then a week wait for the all clear I'm done. Alternatively, I could go to A & E, ham it up a little, get my bloods taken, wait 4 hours for the results and get discharged with piece of mind by a doctor. What's preferable to the patients?! 

This is why year on year ambulance services and hospitals are getting over run! Because between us we provide a one-stop-shop fix to most of our patients. People who are anxious about something want an ambulance to merely give them a check up. They say they can't get a GP appointment so we are the only option they see as viable. It's not the GPs fault either, they are over run with 1000s of people with the most minor or ailments who simply can't cope with a days pain or discomfort. We as a country are become less and less able to deal with illness! And why?! Because we have been nannied for too long! People can no longer cope with a cold or a chest infection. There is a huge expectation on what medical professionals can do and the magic wands that we carry. 

I think there are two things that have to happen. I think a move away from the traditional GP surgery and a greater use of GP led walk in centres and urgent care centres needs to continue to grow. Secondly, the NHS has to stop being so risk adverse and needs to say no to people. The second someone says they have had their back pain for 5 days you say no. No ambulance. No GP appointment. Go to your nearest Walk In Centre using your own means of travel, a bus or a taxi and wait to be seen. Don't do that until you've attempted treating it yourself with pain killers, anti-inflamatiries, heat packs and rest. The problem is, that conversation and history taking takes time. The government insist on the absurd 8 minute target so the ambulance service is forced to use a triage system that is scared of saying no quickly. The use of others take longer and that is time we don't have. 

The old adage of everyone needing to work together is a cliche, but true. GPs need to work with other areas of healthcare more closely, as do ambulance services and A & Es. The problem is, everyone has their own pressures and their own targets to meet and that is the priority to each trust. No one wants fines for failing. Therefore, just as with the patients, organisations behaviour is relevant to previous experience. If they have been fined in the past, they will do everything possible to avoid it in the future. If that means abusing another trust, department or organisation then so be it. 

We are all in this together, but we aren't working together to fix it.

Monday 6 October 2014

The Good, The Bad and the Ugly

"66 year old institution, near collapse."

I don't really know where to start on this one. Usually I am ready to commentate on all things ambulance, especially when we are in the news, being thrown under the bus or maligned. A few months back The Spectator published the first of two articles regarding the current crisis within the ambulance service. It touches upon the amount of frontline staff leaving in their droves, and asks the very simple question, why? Fast forward a month and a second article was published, in what was a hard hitting, painful accurate portrayal of the crisis facing Londoners and all the ambulance services up and down the country. The official line, was that everyone was leaving because of pay and cost of living. Sadly, this couldn't be further from the truth. Whilst the article had some inaccuracies and was biased in some areas, the theme and overall mood of the piece was spot on. 

As I sat doing paperwork after dealing with a total time waster I listened to an urgent request for a vehicle, for a child vs a bus, trapped and screaming. I was a good 10 miles away but offered up all the same. 18 minutes later, I was shocked to discover that I was first on scene, on my own, in a car. To cut a future post short, the injuries were horrific, the child was in a grave situation and there was so much to do in terms of injury management that I needed more than my pair of hands. Unfortunately, more pairs were not forthcoming. It was an hour before backup arrived. An hour with a patient who's injuries still haunt me. An hour with the crying, screaming, panicked family, friends, neighbours and members of the public. If there was ever a situation to highlight the current crisis, it was here and now. With call demand rising week on week, staff leaving day by day and sick levels at an all time high, it certainly feels from where I am sitting that there is no way out. It feels like the ship is sinking, and everyone around me is jumping.

Over years of working with the same people, you forge very close friendships. Friendships which in many ways you rely on as part of your working day. I ended up with a close group of 5-6 friends with whom I could laugh with, confide in and socialise with. Within the last 12 months, all of them have left. Some to other ambulance services, others to other areas of healthcare. None of them cited money as the reason for leaving. The main theme was a lack of respect, lack of career progression, exhaustion and working conditions. The ones who went to other areas of healthcare, who don't necessarily enjoy their new job say 'well at least it's not the ambulance service'. People have quite simply had enough. 

From a personal point of view, I stopped blogging because I had nothing positive to say. Every day at work filled me with more negativity. And negativity breeds negativity. There was nothing I could write, without it sounding miserable and that's not what I'm about. The crisis within the ambulance service is caused by a domino effect of knee-jerk reactions from top to bottom of the NHS. The main issue from where I am standing, is the fact that for too long, the NHS functioned well but propped up by good will. Remove the good will, and everything slowly collapses. 

The Tory government insisted on huge cuts across the board and no matter what comes after, these ill advised, poorly implemented cuts to aid privatisation are the root cause of the problems. They are not the sole reason behind the current crisis though. Ambulance chiefs had to make savings but did so in panic and with what appears to be with little thought or planning. Again, it was a knee-jerk reaction. The problem was, in the panic, they made cuts in the three areas where cuts should never be made. They stopped investing in recruitment, the stopped investing in training and stopped investing in equipment. That left what was essentially a time bomb, and sure enough, 4-5 years on, that bomb has exploded. Richard Branson once said that "you must train your staff well enough so they can leave and treat them well enough that they don't want to". By doing the opposite, a mass exodus was inevitable. Unfortunately, by dangling the carrot of money, the service continued to just about cope with a lack of staff by filling the gaps on overtime. Time and a half, then double time, then triple, then double plus a bonus, then triple plus a bonus. Whilst this happened though, the void behind the good will got bigger and bigger. Eventually, the good will wasn't enough and in many cases stopped altogether. Fed up with being run ragged day after day, on an ancient, poorly kitted vehicle, with no rest break, having had no training for 5 years, and no prospect of career profession people left and on mass. In my service by all accounts it has been 30+ leaving a month, for a long time. And now the exodus won't stop. Day after day, you hear of more good people leaving. And none of them are citing money or cost of living as the reason. At least not to their friends and colleagues. 

The management are trying to solve the problem, they really are, but there is only so much that they can do. The problem is though, they made widespread, wholesale changes to the working lives and practices of staff with little consultation. In fairness, the changes had to be made. Again, it was the lack of change in a previous regime that led to it, but it's one thing to change practices during the working day, another to effect peoples family life. As much as this has had a negative effect on staff, this didn't cause the crisis, it was more a result of the crisis. Morale is at such a low ebb now, every promise of new staff, new vehicles and more training is met with cynicism, sarcasm and more resignations, and in many ways, rightly so. There is no trust any more. Unfortunately, the actions of previous management teams will continue to make the current ones efforts to solve it, near impossible.

This is the point at which I am getting frustrated though. It is all very well moaning about what is wrong, but personally, if you're going to moan, you have to be willing to work to help fix it. Sadly, you're left with half a workforce who are willing to help change things, willing to make positive suggestions and act upon them, and other half who won't, who block positive change, dig heels in and who spread a feeling of bad will throughout the work force. And it is THIS makes any positive change very slow to appear. Too slow in fact, to stop the rot. I also think the unions should be bearing the brunt of the blame when it comes to this. For too long they didn't represent the interests of the staff. The reps looked after themselves and saw their role as a great opportunity for time off the road, ignoring the wishes and concerns of large chunks of new staff and relief staff all because they were not considered  'core staff'. This fragmentation has led to the divide in working relations and is the cause of many newly qualified paramedics leaving the service after just a few months service.

The problems have been caused not only by lack of funding and lack of management but also poor working practice on behalf of some front line staff, throughout the NHS. It would be unfair to lay all the blame on the doorstep of managers. We as a work force should be taking responsibility for some of the issues we are faced. Call volume is at an all time high, the consequences of which we all face,  and various initiatives are being brought in to combat this. Hear and Treat, alternative care pathways, various streaming techniques and patient ring backs are all being used to try and lessen the impact on hospitals and the service. Not all staff are willing to help though. There are those who will take everyone to hospital because 'that's my job'. It is all well coming up with a solution but if everyone doesn't pull in the same direction you're left with a stalemate. 

There are some FRU's who cancel most ambulances, discharge and refer and try to save resources. There are others who won't cancel an ambulance and deal with the patient themselves because it means more paperwork or they are too risk adverse. There are ambulance crews who use as many alternative care pathways as possible and will offer up for calls being held. There are others who will sit there and not offer up for even a cardiac arrest being broadcasted because they are fed up being off late or haven't finished their tea. There are staff who drag their heels with everything they do from activation to at hospital times, just because they have had enough. There are some team leaders who are proactive and look after their staff, keep them current with their development and lead by example clinically. There are others who do literally nothing for their team and just come to work, take everyone to hospital and go home. There are good managers who manage staff well, and bad managers who don't. All positive dealings with any job role, any department and any service is always superceeded by the bad experiences. And here for me is where the problem lies. There are the good and the bad in every level, throughout the ambulance service and naturally, it is the bad that stalls progress. For too long the NHS has allowed bag eggs to stay in their jobs, preventing good people from progessing. There is a culture of blame and no cohesion within the ambulance service and people quickly become disillusoned. The camaraderie that once was, is diminished. The good will that held the service up is gone. The pride in the job we once had, is non-existent and you're left with a self destructive, miserable, tired workforce. 

And who suffers because of all of this infighting, poor working practice, bad management, budget cuts, staff resignations? The patients. The boy lying in front of me, screaming, his parents crying, his friends terrified. They don't care about all the crap. They don't care if we are recruiting from abroad. They don't care in our training course was cancelled. They don't care if it's the fault of the government or the fault of the previous management team. They don't care if the ambulance is old or if our rotas are changing. They care about why there is no ambulance in the here and now. We all have issues, but we have one fundamental responsibility, and that is to provide care to the people who need it, when they need it, in a professional and timely fashion. Anything short of that is a critical failure. 

The ambulance service is broken, there is no hiding from that, but if we want to fix it, everyone has to work for it. There is no switch, no quick fix. There are some people who need to take a long hard look at themselves and decide if this is the job for them. In the last few months I have been disgusted with the attitudes of some and the behaviour of others. It's disruptive and doesn't help the problem. There is so much to be proud of within the NHS, but if we continue to act to the detriment of the patients, it will only pave the way for full privatisation, and that would be a grave grave day. If you are not part of the solution, you are part of the problem.