It’s time to decide: emergency or everything?

Recently I wrote an article on LinkedIn expressing my thoughts about the ongoing challenges between the traditional expected role of the ambulance service and the one in which it finds itself today.

Receiving over 28,000 interactions across LinkedIn, the article garnered comments and feedback from clinicians across the globe; similar healthcare systems facing the same issues with ambulance service utilisation, and the ongoing concerns around their scope and purpose. What was perceived to be a British problem appears to be an international issue, and one which shared learning and experiences can undoubtedly improve a generation’s use of healthcare.

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Ambulance services have always been thought of as emergency services; the people you call in life and death situations. British ambulance services have become an extension of primary care, urgent care, social care, mental health and Google-search care, and it’s having a chronically negative impact on service provision and retention of staff.

The current format is based upon a mindset of ‘everyone welcome’ rather than ‘do you really need us?’ and subsequently ambulance crews find themselves involved in jobs that other healthcare providers should/could be dealing with, or low impact/mild illness that adults should be handling themselves. The days of those with broken arms on a rugby pitch being loaded into cars and turning up at A&E in a t-shirt sling, a few tears but no major harm done are gone.

Ambulance services primarily operate on a four-tier triage system, where category one is the most serious, and four the least. Ambulance services have clinicians in the control room to triage the low acuity calls in more detail, however many only have a handful of people able to do this. These clinicians can range from nurses to paramedics and doctors, and it does depend greatly on where you work on how much input these individuals have.

The current operational format for ambulances on the road promotes ‘One paramedic on every ambulance.’ While this sounds like perfection, few patients come close to needing a paramedic’s skillset, and often paramedics could be better used calling category three and four calls back, clinically triaging them, and sending them via alternative care pathways where applicable.

Use of technicians

In my experience, ambulance technicians (including similar grades) can achieve the same outcomes in many instances, and this is largely due to services absorbing other healthcare issues, many of which simply aren’t the job of the traditional ambulance service.

Technicians are not a cheap or easy way out, and there is evidencable risk across the NHS where clinical decisions made by non-registrants lead to harm, however that doesn’t mean the wider system around them can’t adapt to offer greater support than ever before. Services could reduce risk significantly utilising video consultations and triage, AI and more. There are plenty of opportunities for junior colleagues to have a supported discharge process in place with senior clinicians overseeing where necessary.

Potential way forward

So how to progress? Where to go? It comes down to what you think your ambulance service should do. Paramedics are leaving the ambulance services in droves, so something must change. Here are my suggestions.

1. Clinical triage of all category three and four calls prior to ambulance dispatch
2. Reintroduction of response cars for specialist clinicians
3. Reduce emphasis on paramedic ambulances; reconsider rapid response vehicles instead in clinical support roles to utilise technology/support non-registrants
4. Create a new ‘Pre-Hospital Care Service’ to absorb both ambulance and primary care services
5. Introduce advanced clinical practitioners (ACP) such as mental health specialists, primary care specialists, district nurses and physios into a wider ‘Pre-Hospital Care Service’ rather than focusing purely on ambulances and emergency departments.

There is a wide variety of healthcare practitioners within the NHS that could support the ambulance service, with ACPs being a good example of this. Would an ACP be beneficial working in communities bridging the gap between emergency and urgent/primary care? Probably, and many of these staff are already paramedics. I don’t know of anyone working as an ACP in the ambulance service currently with full autonomy and prescribing, and I imagine it has a lot to do with mindset and finances.

Approach to non-critical care

Ambulance services pride themselves on having critical care paramedics or advanced paramedics in critical care”. Fantastic, but what about the 95 per cent of other jobs that come to services that have little to do with critical care?

ACPs are Band 8a clinicians in most hospital Trusts. Working as a locum, they can earn upwards of £55 an hour. If we want to improve our clinical offering, we must accept that agenda for change in the ambulance service may not work, and expert/senior clinicians cost more money than we are used to spending.

Geriatric medicine is a specialism within the hospital environment, yet when it comes to pre-hospital care there are zero specialists in older people. Why? Geriatrics are likely our singular highest need patient group who take up a huge volume of resource and time. Why wouldn’t you have geriatric specialists and clinicians within ambulance services?

Continued problem of handover delays

Hospital handover delays are clearly a cause for concern, and something which demoralises clinicians and delays treatment for patients. While hospitals across the UK must do better at offloading ambulances, consider how many of those patients must be there versus how many have been taken there due to a deficiency in alternative care pathways or senior clinicians able to manage their needs otherwise.

Globally, the pattern of overuse of ambulance services, redefining their purpose and redesigning of education and training couldn’t be clearer. The disconnect between general practice, primary and secondary care, as well as ongoing complex healthcare needs is evident across multiple national healthcare provisions and is being felt by pre-hospital clinicians across the globe.

Current ambulance systems cannot sustain the call volume and requirement of modern patient demographics, and ground-up system redevelopment, as well as clinical role introduction and refinement is essential to deliver the best healthcare to patients prehospitally going forward.