Driven to the edge? An insider’s view of the Belfast Ambulance service

South Western Ambulance WA07RYP 612Due to the ambulance strike today we are republishing this post as it helps explain the background to the strike. We have also kept the original comments – feel free to add new comments.

Continuing our series on health, we hear from a paramedic about the challenges the service is facing.

As a Paramedic working on an emergency ambulance it was encouraging to read George O’Neill’s article on Slugger last week that recognised the vital role of the ambulance service in managing the future delivery of unscheduled care in Northern Ireland. I would like to take this opportunity to provide an honest assessment of the current capability of the ambulance service and it’s potential to fulfil this new role.

Emergency ambulances here are staffed by Paramedics and Emergency Medical Technicians (EMT’s). They deliver babies, pronounce life extinct and cover absolutely everything in between. They are consummate jack-of-all-trades. A Paramedic is licensed to independently administer 35 different drugs, manage major trauma, resuscitate you in the event of a cardiac arrest and stabilise many medical problems. We work in highly pressurised environments with minimal training and without the safety net of having specialist doctors and nurses nearby.

A typical shift could see us carrying a 20 stone patient having a heart attack down 3 flights of stairs, then being called to a house where an individual has suffered a sudden death, liaising with police and doctors and above all sensitively dealing with grieving relatives. We could then end up at a major road traffic accident before having to talk a suicidal person into travelling to hospital. And all before lunch!

This illustration is not exaggerated. The nature of the work, the diversity of situations, difficult working environments and the high range of emotions involved means we regularly put our mental and physical health on the line for the benefit of our patients. Yet one of the cardinal sins of ambulance work is acting as if what we do is a big deal.

Unfortunately, the problems highlighted in the media faced by our Emergency Departments are very much present within the ambulance service. A growing elderly population, many of whom have chronic conditions requiring frequent interventions coupled with the misuse and abuse of emergency ambulances by both the public and health professionals has led to a dramatic increase in 999 calls and is forecast to continue to rise for the foreseeable future. Budget cuts mean that ambulance numbers have been slashed leaving a service under mounting, and many would say unsustainable, pressure.

By rights Northern Ireland should have an ambulance service at the cutting edge of pre-hospital medicine. The man known as “The Father of Emergency Medicine”, Professor Frank Pantridge, was a cardiologist at Belfast’s Royal Victoria Hospital. He introduced the technique of CPR and mouth to mouth resuscitation for cardiac arrest and went on to develop the first portable defibrillator in 1965. Dubbed the “Pantridge Plan”, this protocol forms the basis for treatment of cardiac arrest around the world today and has saved countless lives . Unfortunately despite rapid uptake by countries such as USA, Canada and Australia, defibrillators were not installed in UK ambulances until 1990.

However, we have not capitalised on this fine heritage.

The service is now reduced to operating a maximum of seven ambulances to cover the Belfast area (approx 280,000 people), with the rest of the country no better.

The system works to capacity most of the time, with little slack, meaning that sustained seasonal pressures or major incidents cause serious problems for staff and unacceptable delays for patients. Given the sparsity of cover,  the trigger point for such major incidents is lower that you would expect, the Hardwell gig at The Odyssey being a recent example.

The increase in workload for crews means that we regularly go a 12 hr shift being stood down for only one 30 minute meal break, which can be as late as 7 or 8 hours into that shift. Even this can be disturbed if an emergency call needs to be answered. Finishing our shift on time is rare.

Forefront in our minds is the welfare of patients. If we go from call to call with no meal break until the last third of the shift, stress increases, performance decreases and mistakes will be made. I for one do not want to be lying in bed awake at night because I have caused a patient harm.

This plays out against a backdrop of a management team more concerned with crisis management and blaming staff instead of dealing with the root causes of the organisation’s problems.

Their obsession with response times has resulted in paramedics being taken out of ambulances and put into single man cars, solely as a clock stopping exercise and regardless of whether this is the most beneficial model for the patient. Despite this we still don’t meet response time targets but nobody really seems to care.

Holding the organisation together at the moment is the professionalism and goodwill of it’s front line staff. However this cannot go on indefinitely. Sickness rates are high due to stress and musculoskeletal injury. Staff shortages result in dropped crews and more work to be picked up by the rest of the workforce, as well as casual leave not being covered. It doesn’t take a genius to work out how this then leads to a perpetual cycle of stress and sickness.

I wholeheartedly agree with up-skilling paramedics to allow us to treat people in their own homes. This will alleviate pressures in ED’s but will do nothing to ease ours. We need investment in new skills but also more ambulances. We need a good foundation to build on for the future, not something optimistically tacked on to the existing creaking structure.

Above all we need a level of pay commensurate with the demands of the job. Paramedics will welcome the opportunity to enhance their professional practice, but before we ask them to become doctors on the cheap and take on even more responsibility we would need to see a matching financial commitment. Despite almost all job roles being evaluated under Agenda for Change when it was introduced ten years ago, our management have spent the last decade quibbling over minor details, seeking to deny us the points that would take us into the next pay band. A newly-qualified Paramedic (Band 5) earns a salary of around £21K,  receiving annual increments for seven years to reach a maximum of £27K. Achieving Band 6 would see our pay rise to £25-34K.

Too many people dial 999 who do not require an emergency response. This ranges from wilful abuse to unintentional misuse and is not isolated to any one section of the community. If the number of these unnecessary callouts could be reduced we would see some flexibility returned to the system, but how could we address this?

Charging people for calling out an ambulance inappropriately is a popular idea but it is fraught with complications. Many of the worst offenders would be unable to pay, and pursuing the non-payment of fines through the court system could potentially cost more than would be recouped. It would also send out the wrong message to genuine service users – call us out and you may be charged if your condition is not deemed serious enough. This couldn’t be further from the original ethos of the NHS. No-one in our line of work would ever support a system that could cause a patient to think twice before lifting the phone for help.

Currently we cannot refuse to take a person to hospital, no matter how trivial the complaint. Not taking certain patients to hospital seems an attractive option as it would reduce the amount of time an ambulance is unavailable to respond to other emergency calls. However I also think this suggestion is unworkable. Given the numerous atypical presentations of certain medical conditions any exclusion criteria used would be so restrictive that it would apply to very few people. Many Paramedics would probably not want to take the chance of leaving a person at home, as inevitably someone will fall through the net and not receive the proper treatment despite the protocol being followed correctly. Besides even regular abusers of the service will get sick sometimes.

I think the most realistic solution will be to improve education on how to properly use the service. Many people are either unsure about what alternatives are available or how to access them. We would never seek to deny an ambulance to anyone who needs one but we need the public to act responsibly when they require unscheduled care to ensure we can continue to provide the best possible outcomes for those most in need.

Sometimes the simplest solutions are the best, and whatever way you view the situation extra ambulances would help.

It seems unrealistic to expect an increase in the number of ambulances given the next round of swingeing budget cuts across most departments, but I would suggest that for short-term investment there could be long term savings. Patients could be treated at home by Paramedics in conjunction with GP’s and Allied Health Professionals at a fraction of the cost of hospital admission. But this model would seem unworkable given the existing number of ambulances.

The ambulance service desperately needs to change, both to respond to future challenges and also for the sake of it’s employees. The goodwill is evaporating, with many staff of the opinion that their commitment is not being reciprocated.  I am confident however that if you are ever unfortunate enough to need us you will always receive the highest standard of care possible. We act as the buffer between service reduction and patient safety and will continue to do so, but we would urge the department to recognise the dedication of all it’s frontline staff by alleviating these pressures, paying us for the job we do and above all giving us the tools to improve patient outcomes.

What do you think? Let us know your views in the comments below. We are keen to hear from other health professionals. If you are a nurse, doctor etc with a view on the health service, do feel free to contact us with your story brian@sluggerotoole.com

This is a guest slot to give a platform for new writers either as a one off, or a prelude to becoming part of the regular Slugger team.