Key areas of interest for paramedics in 2018

June 11, 2018 Leave a comment

My Post (11)The most substantial development concerning paramedics this year is prescribing. Proposals to introduce independent paramedic prescribing were made to the Commission on Human Medicines (CHM) in 2015. However, the CHM did not support the proposals at that time. The College of Paramedics and NHS England went back to the CHM in July 2017 with case studies and an implementation plan to try and get further discussion. The following December the CHM decided to support independent prescribing by paramedics. It will now recommend implementation by making a submission to government ministers.

There is still a lot of work to be done and this is likely to be the key area for development of the profession in 2018. Legislation changes need to be made to enact the recommendation. Universities will have to develop their prescribing programmes and the Health and Care Professions Council (HCPC) will need to update its Standards for Prescribing. While it is unlikely there will be any paramedic prescribers until 2019 at the earliest, this marks a key progression in the development of the profession.

In September 2017, the HCPC began consulting on the threshold level of qualification for entry to the register for paramedics. The current level is outlined in the HCPC Standards of Education and Training at ‘equivalent to Certificate of Higher Education for paramedics’. However, the Paramedic Evidence Based Education Project (PEEP) report recommended the level to the paramedic register be raised to BSc (Hons) degree by 2019.
The consultation document proposes the level of qualification should be amended, due to the changing nature and complexity of the role of paramedics, and it illustrates the ongoing diversity in current qualifications across the UK. Any resultant change would not affect existing registered paramedics or students who are part way through pre-registration education and training programmes. The consultation closed on 15 December, with the outcome expected early this year.

Clinical practice

The UK Ambulance Services Clinical Practice Guidelines, last published in 2016, published supplementary guidelines last year. Although there will not be a new version of the guidelines this year, ongoing updates continue to be published online.

The National Institute for Health and Care Excellence (NICE) is updating its Quality Standard on Trauma. This quality standard covers assessment and management of trauma (complex fractures, non-complex fractures, major trauma and spinal injury) in adults, young people and children. It does not cover hip fracture or head injury as these topics are covered in a separate Quality Standard. The draft quality standard was open for consultation from 7 November to 5 December. The final Quality Standard is expected to be published on 29 March 2018.

Initial results from the AIRWAYS-2 trial are likely to be seen in spring 2018. This randomised trial is comparing the clinical and cost effectiveness of the i-gel supraglottic airway device with tracheal intubation in the initial airway management of patients suffering an out of hospital cardiac arrest.

At the time of writing, the final publication of the College of Paramedics’ position statement on paramedic intubation is still impending. Work began in May 2017 on the statement, with a group meeting in July to discuss and develop a first draft. This statement was reviewed and amended by several key clinical groups before being released to the membership and wider stakeholder organisations for comment. Consultation ran in September 2017, with final publication imminent.

Service delivery

NHS England and NHS Improvement have called on all A&E Delivery Boards to implement measures to reduce the impact of ambulance handover delays. They have outlined key principles concerning actions to be embedded as part of normal working practice, and actions to be taken should ambulances begin to queue.

Among the principles, they state acute trusts must always accept the handover of patients within 15 minutes of an ambulance arriving at the emergency department; that leaving patients waiting in ambulances or in corridors supervised by ambulance personnel is inappropriate; and that the patient is the responsibility of the emergency department from the moment that the ambulance arrives, regardless of the exact location of the patient. It will be interesting to see if the implementation of these measures will have an impact on reducing ambulance handover delays in 2018.

Ongoing feedback on the roll out of the Ambulance Response Programme (ARP) will continue throughout the year. The ARP saw changes to the triage of calls, known as dispatch on disposition, to allow more time for call handlers in cases that are not deemed as immediately life-threatening. Additionally, new call categories were introduced to better reflect the wide range of needs patients have when they dial 999. It is likely there will be national updates on the effectiveness of the ARP, hopefully with benefits of the change being seen, in 2018.

The NHS was promised £1.6 billion for 2018/19 and £900 million for 2019/20 in the autumn budget. While this is certainly welcome relief, it is still a far cry from the £4 billion health experts said the NHS needed. It is believed £1 billion of the cash pot for 2018/19 will be used to improve performance against the 18-week target for elective treatment and £600 million to help hospitals meet the 4-hour target in A&E.

Conclusions

These are just a few of the elements that will affect paramedics this year. Other areas not mentioned include the Assaults on Emergency Workers (Offences) Bill 2017–19, development of the nursing associate role, the national programme to support allied health professionals to return to practice, and the final report of the Asthma Audit Development Project. There are many challenges facing the NHS in the coming year, but with the upcoming developments in the profession, paramedics will find themselves in a key position to alleviate many of these pressures.

Taken from Journal of Paramedic Practice, published January 2018.

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Whole system change needed in gender identity services

April 18, 2018 Leave a comment

My Post (5)Gender identity services in the NHS are failing to meet the needs of patients. Huge delays in treatment are forcing many to go private or abroad, while a lack of funding and suitably trained staff means patients are not receiving adequate care.

Gender dysphoria is a condition whereby a person experiences discomfort or distress because there is a mismatch between their biological sex and their gender identity (NHS Choices, 2016). Figures estimate there are 650 000 people in the UK living with gender dysphoria, which is equal to 1% of the population (Women and Equalities Committee, 2016). This is expected to rise as society’s increasing tolerance and acceptance of transgenderism has encouraged more people to come forward and seek medical help.

In the UK, transgender people’s health needs regarding gender dysphoria are being met at specialised NHS gender identity clinics or through private care. At present, all GPs in England, Northern Ireland and Scotland may refer their patients directly to a gender identity clinic, and do not need to refer them to a mental health service for assessment beforehand. In Wales, however, GPs have to refer first to a local psychiatrist, who assesses the patient and can recommend they are referred for assessment and treatment at a gender identity clinic (General Medical Council (GMC), 2017).

Unacceptable waiting times

Waiting times for people with gender dysphoria before their first appointment at an NHS gender identity clinic are unacceptable, as are the times for subsequent gender reassignment surgery, should it be wanted. This, in turn, has a massive impact on the health and wellbeing of trans patients. According to the GMC, the risk of self-harm and suicide for trans people is much greater than in the general population, and any delays in accessing medical care can substantially increase these risks (GMC, 2017).

Under the NHS Constitution, patients are legally entitled to have their first appointment at a specialist service within 18 weeks of referral (Department of Health, 2015). However, due to increased demand, some transgender patients have found themselves waiting up to 4 years for an appointment (Lyons, 2016). Remarkably, it was only in January 2015 that the NHS accepted that the 18-week principle applies to gender identity services too (Women and Equalities Committee, 2016).

It is because of these long waiting times that many trans people are turning to private care—but this does not come cheap. Initial appointments can cost between £220 and £280, and tend to cover assessment, diagnosis and recommendations. It is generally after two appointments that hormone therapy is started.

The cost of gender reassignment surgery varies considerably and prices range from £10 000 to £20 000. In desperation, many are turning to far-flung destinations, such as Thailand, to have this surgery.

Things need to change

In an attempt to meet the increased demand on gender identity services, NHS England invested an additional £6.5 million in this area this year. It is hoped this will go some way to reducing waiting times. However, despite increased funding, there is no detracting from the stark truth that the NHS is letting transgender people down. Notably, according to a Government report on transgender equality, the NHS is ‘failing in its legal duty under the Equality Act’ (Women and Equalities Committee, 2016).

A lack of knowledge and understanding among many clinicians and staff within the NHS has meant transgender people all too often encounter significant problems, whether through prejudice or the provision of inappropriate care. Additionally, other commonly cited concerns include too much variation in clinical protocols, confusion about what is available in the NHS, and inequitable access arrangements (Women and Equalities Committee, 2016).

Following this report, NHS England asked its Clinical Reference Group for Gender Identity to make recommendations on new service specifications for these specialist clinics. This led to a 12-week public consultation on proposals for new service specifications that, if adopted, will describe how specialised gender identity services for adults will be commissioned and delivered in the future within England. The final decisions will be made at the end of autumn 2017.

Relationship between public and private services

Among the changes set out in the consultation include a proposal that only designated specialist gender identity clinics will be able to refer individuals for reassignment surgery in the NHS. This would mean other NHS professionals or private clinics would not be able to make the referrals. The decision was made because it is felt the multidisciplinary teams of gender identity clinics are best placed to consider an individual’s suitability for surgery in the context of the relevant medical, psychological, emotional and social issues (NHS England, 2017). They are also able to accurately gauge the likely range of risks in each case.

Unfortunately this means patients would be unable to begin down the private pathway of care for an initial assessment and diagnosis, before moving to the NHS for gender reassignment surgery. Though this would go some way to diverting pressures on NHS services, it could be argued that boundaries of care between private and public could be blurred, making it difficulty to ensure safety and quality of care. Equally, referrals to an NHS gender clinic would have to come through an NHS pathway.

A gender identity specialism is needed

The lack of suitably trained staff to take on specialist roles being created in nursing, medicine, psychology and other professions is one of the key reasons for unprecedented demand on gender identity services. There are under a dozen people in the UK working both privately and in the NHS who can carry out vaginoplasty or phalloplasty operations (Parkins, 2016).

With the above in mind, there have been discussions with Health Education England, the GMC and the Royal College of Physicians about the development of a gender identity specialism, supported by appropriate curricula and recognition. It is evident that this is sorely needed; however, even at a grassroots level, training for GPs is insufficient, consisting of two online educational modules on gender variance on the Royal College of General Practitioners’ website. Without a proper understanding of this patient population, health services cannot begin to address their needs.

Conclusion

While momentum for change is gathering and the Government is beginning to listen, anything short of a whole system change in gender identity services would be insufficient. Waiting times are the most pressing concern that need to be addressed, with demand and capacity out of balance. Quality indicators are needed to assess quality and benchmark providers; a better interface with primary care services is essential; and increased understanding and knowledge across all health services is paramount. Transgender people have just as much right to care as anyone else, and health services and professionals cannot let them down.

References

Department of Health. NHS Constitution for England. 2015. http://tinyurl.com/d7sa3wq (accessed 23 October 2017)

General Medical Council. Good medical practice. Trans healthcare. Treatment pathways. 2017. http://tinyurl.com/grugw8z (accessed 19 October 2017)

Lyons K. Gender identity clinic services under strain as referral rates soar. 2016. http://tinyurl.com/hcb9uzz (accessed 19 October 2017)

NHS Choices. Gender dysphoria. 2016. http://tinyurl.com/ybt7rbj7 (accessed 19 October 2017)

NHS England. Guide to consultation: specialised gender identity services for adults. 2017. http://tinyurl.com/ydg3pfmh (accessed 19 October 2017)

Parkins K. Meet the gender reassignment surgeons: ‘Demand is going through the roof’. 2016. http://tinyurl.com/hdblcpg (accessed 19 October 2017)

Women and Equalities Committee. Transgender equality: first report of session 2015–16. 2016. http://tinyurl.com/y8sftc2h (accessed 19 October 2017)

Taken from Journal of Aesthetic Nursing, published November 2017.

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Review of Mental Health Act must address excessive detention rates

April 17, 2018 Leave a comment

My Post (4)Theresa May’s speech at the Conservative Party Conference on Wednesday 4 October was one mired by illness, a prankster and a backdrop that fell apart, presenting journalists with countless opportunities for cheap metaphors. But while the gaffs of her mea culpa overshadowed the announcement of new policies, for those that could see past the cringe-induced spectacle there were a number of interesting points.

One of these announcements was how the Government would be carrying out an independent review of the Mental Health Act. Building on her Brexit speech in January, where she vowed to correct the ‘burning injustices’ in modern society, May explained how a particular priority for her was ‘tackling the injustice and stigma associated with mental health’ (May, 2017).

She emphasised her desire for parity between mental and physical health through reiterating the Government’s pledge of increased investment in mental health. Recent announcements of an additional £1.3 billion to transform mental health services by 2021 (Health Education England, (HEE), 2017) were met with mixed reactions from key health bodies. It was said the funding will go towards the creation of 21 000 new posts, including 4600 nurses working in crisis care settings and 1200 nurses and midwives in child and adolescent mental health services (Department of Health, 2017). However, organisations such as the Royal College of Nursing said the Government’s proposals ‘appear not to add up’ (Royal College of Nursing, 2017). Other policies include giving an extra 1 million patients access to mental health services at an earlier stage, round-the-clock services and the integration of mental and physical health services for the first time.

The Mental Health Act

The Mental Health Act was passed in 1983 and is the main piece of legislation that sets out when and how a person can be detained and treated in relation to their mental illness. People detained under the Mental Health Act need urgent treatment for a mental health disorder and are deemed to be at risk of harm to themselves or others. In May’s speech she argued that the three decades old legislation is leading to ‘shortfalls in services and is open to misuse’ (May 2017). While the Mental Health Act was amended in 2007, it is felt by many that a more substantial revision is needed. This amendment was originally a proposed bill, but many felt it was ‘too draconian’ (BBC news, 2007).

The Five Year Forward View for Mental Health called for the Mental Health Act to be revised ‘to ensure stronger protection of people’s autonomy, and greater scrutiny and protection where the views of individuals with mental capacity to make healthcare decisions may be overridden to enforce treatment against their will’ (Mental Health Taskforce, 2016).

Reducing detention rates

Current detention rates under the Mental Health Act are too high. The latest published figures show the number of detentions under the Act are rising annually, increasing by 9% to 63 622 in 2015–2016, compared to 58 399 detentions in 2014–2015 (NHS Digital, 2016). Over the last 10 years they have increased by almost 50%. Of those detentions, a disproportionate number are of people from black and minority ethnic populations — four times as many black people as white people are detained. It is unclear why there are disproportionate detention rates between different communities, but this must be identified to ensure equal access to earlier intervention and crisis care services.

While reviewing the Act will use changes in legislation to help reduce the rates of detention, the difficulty will come in figuring out how the delivery of care must be changed so that detention can be avoided in the first place (Wessely, 2017). Additional focus is needed on the provision of earlier support. By identifying vulnerable people and addressing their mental health needs early, they can receive the support and care they need before detention becomes an unavoidable necessity.

For those that are detained, there needs to be a review of the areas constituting a ‘place of safety’. Police custody is not an appropriate area of safety. Around half the deaths that take place in or following police custody involve detainees with some form of mental health problem (Independent Police Complaints Commission (IPCC), 2017). Although police custody is only used as a last resort, it can exacerbate a person’s mental state, and has the effect of criminalising people who are in need of medical attention (IPCC, 2017).

Undertaking the review

The review will be carried out by Sir Simon Wessely, professor of psychological medicine at the Institute of Psychiatry, King’s College London. He is the former President of the Royal College of Psychiatrists and current President of the Royal Society of Medicine. Wessely will produce an interim report in early 2018 and develop a final report containing detailed recommendations, by autumn 2018.

References

BBC News. Ministers lose Mental Health vote. [Online]. 2007. [Cited on 25 Oct 2017]. Available from: http://news.bbc.co.uk/1/hi/uk_politics/6374547.stm

Department of Health. Thousands of new roles to be created in mental health workforce plan. London: The Stationery Office; 2017 Aug 30 [cited 2017 Oct 18]. Available from https://publichealthmatters.blog.gov.uk/2017/08/30/moving-forward-with-theprevention-of-mental-health-problems/

Health Education England. Stepping forward to 2020/21: The mental health workforce plan for England. Leeds: Health Education England; 2017 [cited 2017 Oct 18]. Available from https://www.hee.nhs.uk/sites/default/files/documents/CCS0717505185-1_FYFV%20Mental%20health%20workforce%20plan%20for%20England_v5%283%29.pdf

Independent Police Complaints Commission. Mental health and police custody [Internet]. Sale: IPCC; 2017 [cited 2017 Oct 19]. Available from https://www.ipcc.gov.uk/page/mental-health-police-custody

May T. Theresa May’s Conservative conference speech, full text [Internet]. London: The Spectator; 2017 Oct 4 [cited 2017 Oct 18]. Available from https://blogs.spectator.co.uk/2017/10/theresa-mays-conservativeconference-speech-full-text/

Mental Health Taskforce. The Five Year Forward View for Mental Health. Leeds: NHS England; 2016

NHS Digital. Inpatients formally detained in hospitals under the Mental Health Act 1983, and patients subject to supervised community treatment. Uses of the Mental Health Act: Annual Statistics, 2015/16. London: Health and Social Care Information Centre; 2016

Royal College of Nursing. RCN responds to Mental Health Workforce Plan. London: RCN; 2017 [cited 2017 Oct 18]. Available from https://tinyurl.com/yavm3ulq

Wessely S. The Prime Minister Has Asked Me To Lead A Review Of The Mental Health Inequality In Britain – Here’s Why. London: The Huffington Post; 2017 Oct 6 [cited 2017 Oct 19]. Available from http://www.huffingtonpost.co.uk/professor-sir-simonwessely/mental-health-act_b_18192476.html

Taken from British Journal of Healthcare Management, published November 2017.

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Government’s additional £1.3 billion for mental health services is misleading

November 20, 2017 Leave a comment

Adobe Spark (4)The Government has committed £1.3 billion to transform mental health services by 2021 (Health Education England (HEE), 2017). Stepping Forward to 2020/21: Mental Health Workforce Plan for England was launched by Health Secretary Jeremy Hunt, who called it ‘one of the biggest expansions of mental health services in Europe’ (Department of Health, 2017). The funding will go towards the creation of 21 000 new posts, including 4600 nurses working in crisis care settings and 1200 nurses and midwives in child and adolescent mental health services.

Other policies include giving an extra 1 million patients access to mental health services at an earlier stage, round-the-clock services and the integration of mental and physical health services for the first time.

Examining the plan

The scale of these proposals is commendable and reflects the additional staff required to deliver the transformation set out in The Five Year Forward View for Mental Health (Mental Health Taskforce, 2016). Mental health provision has consistently been underfunded, therefore an update to place it more in line with physical health provision is long overdue.

For this reason, the announcement has been welcomed by many mental health campaigners and professionals. The Royal College of Psychiatrists (RCP) led the way in commending the Government’s plans, with Professor Wendy Burn, President of the RCP, saying the 570 extra consultants promised in the strategy will be ‘crucial to delivering the high-quality, robust mental health services of the future’ (RCP, 2017). NHS Employers said service providers will welcome national support, particularly for ‘improved access to funding for continuing professional development for the mental health workforce, and facilitating increased use of international staff where required’ (NHS Employers, 2017).

However, despite the will to welcome these proposals it would be wise to take them with a pinch of salt. While the Royal College of Nursing (RCN) encouraged the investment, it said the Government’s proposals ‘appear not to add up’ (RCN, 2017). RCN chief executive, Janet Davies, stressed that in order for the nurses to be ready in time, they would have to start training straight away. Additionally, she cites how the scrapping of nursing bursaries has led to a ‘sharp fall in university applications’.

Attrition rates on the rise

Attrition rates for all mental health staff are rising. From 2012/13 to 2015/16, the number of people leaving mental health trusts has risen from 10.5% to 13.6% (HEE, 2017). The NHS currently funds over 214 000 posts to provide specialist mental health services in England. However, over 20 000 of these vacancies are predominantly filled by bank and agency staff (HEE, 2017). It is clear the sheer scale of growth cannot be met via the traditional training routes within this timescale, as in some cases this would mean doubling or trebling the workforce. While investment is needed in the development and reskilling of existing staff, or looking to the global market for recruitment, this is an unrealistic aim.

The Royal College of Occupational Therapists (RCOT) is one of the groups who have raised concerns over vacancy rates. Julia Scott, CEO of the RCOT, said health and care services across the country are experiencing real difficulties in filling existing vacancies, with vacancy rates for occupational therapists of up to 50% (RCOT, 2017). She stressed that rapid action is needed to address this crisis if commitment is to be delivered.

The British Medical Association (BMA) echoed worries over recruitment, stressing insufficient psychiatry trainees across England and a high percentage of trainees not completing training in the specialty. BMA consultants committee deputy chair and consultant child and adolescent psychiatrist, Dr Gary Wannan, said: ‘In 2014, one in five doctors undertaking core psychiatry training did not progress into the final part of their training’ (BMA, 2017).

Government pledge still insufficient

Currently, 15.8% of people with common mental conditions access psychological therapies each year. However, even with the Government’s proposals this will only increase to 25% by 2020/21 (HEE, 2017). This is still an unacceptable figure
and one that is emphasised by the UK Council for Psychotherapy (UKCP), who said the announcement falls far short of what is needed to offset the growing demand for NHS mental health services.

According to UKCP Chair Martin Pollecoff: ‘To meet even existing demand, the Government should take advantage of the vast existing workforce of therapists. UKCP alone has more than 8000 highly qualified trained psychotherapists from different backgrounds, and many of them have medical experience’ (UKCP, 2017).

Origin of investment misleading

This is not the first time the introduction of £1 billion for mental health services has been proposed. In 2016, then Prime Minister David Cameron announced almost £1 billion of investment as part of a ‘revolution’ of mental health treatment (Prime Minister’s Office et al, 2016). This commitment from the Government sounds impressive, but has to be considered in the context of cash terms rise in the NHS budget generally. The Government has pledged to increase NHS spending in England to £120 billion by 2020/21
(HM Treasury, 2015). For mental health spending to grow at the same rate as the rest of the NHS, around 11.9% of the extra funding given to NHS England needs to be spent on mental health (Full Fact, 2016). This works out at roughly £2.2 billion. This figure far exceeds the £1.4 billion pledged in the most recent announcement and clearly represents a slower rise in spending than other parts of the NHS.

Simply not good enough

At first glance, the Government’s proposals appear to be the desperately needed boost to mental health services, which should be welcomed. However, the explanations of how additional posts will be funded or the recruitment issues overcome does not add up and are simply not good enough.

The Government has sugar-coated the amount of investment pledged and the figure still falls far below what is needed for mental health. It therefore comes as no surprise that Labour’s Shadow Minister for Mental Health, Barbara Keeley MP, said the workforce plan: ‘offers little hope to those working in the sector faced with mounting workloads, low pay and poor morale’ (The Labour Party, 2017).

References

British Medical Association (2017) BMA responds to Department of Health mental health workforce plans. BMA, London. https://tinyurl.com/ybtgxye8 (accessed 29 August 2017)

Department of Health (2017) Thousands of new roles to be created in mental health workforce plan. DH, London. https://tinyurl.com/y9akdjdr (accessed 31 August 2017)

Full Fact (2016) Unanswered questions on “extra £1 billion” for mental health. Full Fact, London. https://tinyurl.com/y7oyy8qc (accessed 1 September 2017)

Health Education England (2017) Stepping forward to 2020/21: The mental health workforce plan for England. HEE, Leeds. https://tinyurl.com/ycebebna (accessed 25 August 2017)

HM Treasury (2015) Spending Review and Autumn Statement 2015. The Stationery Office, London

The Labour Party (2017) Tory Government promising jam tomorrow when action is needed today to tackle the staffing crisis in mental health – Keeley. The Labour Party, Newcastle upon Tyne. https://tinyurl.com/y7db35pf (accessed 29 August 2017)

Mental Health Taskforce (2016) The Five Year Forward View for Mental Health. NHS England, Leeds. https://tinyurl.com/gvc4or3 (accessed 25 August 2017)

NHS Employers (2017) NHS Employers welcomes plan to prioritise mental health services. https://tinyurl. com/ydg8h3ca (accessed 29 August 2017)

Prime Minister’s Office, 10 Down-ing Street, Department of Health, NHS England, The Rt Hon David Cameron, The Rt Hon Jeremy Hunt MP (2016) Prime Minister pledges a revolution in mental health treatment. Department of Health, London. https://tinyurl.com/z69jcpc (accessed 1 September 2017)

Royal College of Psychiatrists (2017) RCPsych response to HEE’s Mental Health Workforce Plan. RCPsych, London. https://tinyurl.com/yc2p93k8 (accessed 25 August 2017)

Royal College of Nursing (2017) RCN responds to Mental Health Workforce Plan. RCN, London. https://tinyurl.com/yavm3ulq (accessed 25 August 2017)

Royal College of Occupational Therapists (2017) Royal College of Occupational Therapists welcomes an expansion in the mental health workforce. RCOT, London. https://tinyurl.com/ycl9bss2 (accessed 25 August 2017)

UK Council for Psychotherapy (2017) We urge the Government to use existing therapist workforce to plug treatment gap. UKCP, London. https://tinyurl.com/ydfojrpk (accessed 29 August 2017)

Taken from British Journal of Mental Health Nursing, published September 2017.

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More advanced paramedics needed if A&E pressure is to be eased

September 13, 2017 Leave a comment

Adobe Spark (1)The NHS must introduce more advanced paramedics if emergency departments are to meet growing patient demand. The NHS is reaching a crisis point—annual rises in emergency admissions and insufficient resources mean patients aren’t receiving the necessary levels of care. Traditionally, care provided by paramedics has focused on the immediate assessment and management of potentially life-threatening emergencies. This is then followed by transfer to an appropriate receiving unit. However, increasingly, evidence suggests that patients who present to ambulance services with lower acuity presentations could alleviate the need for hospital admission by undergoing assessment and management in the community.

This is highlighted in new draft guidance published by NICE (2017), which should fall on welcome ears to ambulance services. It recommends that the NHS provides more advanced paramedic practitioners (APPs), who have extended training in assessing and treating people with medical emergencies, to relieve pressure on emergency departments.

Evaluating the evidence

In order to make these recommendations, the guideline committee investigated whether enhancing the competencies of paramedics resulted in a reduction in hospital admissions and demand for emergency department services. When considering clinical evidence, three studies were included in the review. Two studies, which came from the same cluster-randomised controlled trial, looked at a paramedic practitioner service in the UK, which gave enhanced training to paramedics.

The first study comprised 3018 people and evaluated the benefits of paramedic practitioners who have been trained with extended skills to assess, treat, and discharge older patients with minor acute conditions in the community (Mason et al. 2007). The evidence suggested that enhanced competencies of paramedics may provide benefit for reducing the number of hospital admissions (0–28 days), emergency department attendance (0–28 days), and patient and/or carer satisfaction. There was no effect on mortality.

The second study comprised 2025 people and evaluated the safety of clinical decisions made by paramedic practitioners of older patients contacting the emergency medical services with a minor injury or illness (Mason et al. 2008). Of the 3018 patients recruited into the randomised-controlled trial, 993 were admitted to the hospital at the index episode, which explains why they were excluded from the analysis in this study. The evidence suggested that there was no effect of paramedics’ enhanced competencies on unplanned emergency department attendance.

The final study was a non-randomised (quasi-experimental) study of emergency care practitioners who worked as single responders to ambulance service 999 calls, compared with standard paramedic or technician ambulance responding to ambulance service 999 calls. The study comprised 1107 people and aimed to evaluate the impact of emergency care practitioners on patient pathways and care indifferent emergency care settings.
(Mason et al. 2012). The evidence suggested that enhanced competencies of paramedics may provide a benefit from reduced numbers of patients referred to hospital (emergency department or direct admission to a hospital ward), and increased number referred to primary care.

Additionally, one cost-utility analysis was assessed to consider the economic implications of providing additional advanced paramedics within ambulance services, and found that the paramedic practitioner scheme was cost-effective compared with the standard 999 service (Dixon et al. 2009). This study was assessed as partially applicable with minor limitations.

Points for concern

There are a number of considerations when looking at the evidence in question that could be cause for concern. While evidence exists, it is minimal, with only one randomised-controlled trial and one non-randomised study evaluated by NICE. Though results from the studies are positive, it would be difficult to generalise them beyond the services assessed. Additionally, the quality of evidence is generally of a low GRADE (Grading of Recommendations, Assessment, Development and Evaluations). The randomised-controlled trial evidence has a moderate-to-low GRADE rating overall, mainly owing to risk of bias and imprecision (NICE 2017). The non-randomised study, although it had large effect sizes, has a very low GRADE rating as a result of high risk of bias and indirectness of the outcomes to the protocol (NICE 2017). The economic evidence was considered high-quality but only partially applicable because the costs were quite dated. Some social care costs were also included, which means that the perspective is not strictly NHS and personal social services (NICE 2017).

There are notable concerns over the definition of an APP, as there is a national lack of consensus over paramedic roles and scope of practice. This was a contributing factor to why independent prescribing by APPs was not recommended by the CHM and MHRA (Allied Health Professions Medicines Project Team 2016).

The need for unanimity across all ambulance services is a concern the College of Paramedics emphasised inits response to the guidance:

‘There has previously been insufficient attention given to career development and career opportunities and there is currently significant variation across the ambulance services in the definitions, titles, education, and training of specialist and advanced paramedics. To ensure consistency of education, training and qualification, the UK ambulance services would need to adopt the frameworks developed by the College of Paramedics, which provide detailed guidance on education, competencies, and career development’ (College of Paramedics 2017).

The College of Paramedics has a clear definition of the APP role in terms of competencies and education:

‘Advanced paramedics are experienced autonomous paramedics who have undertaken further study and skill acquisition to enable them to be able to deliver a more appropriate level of assessment and indeed care to patients in the community and access many more referral pathways.’

It is essential that this becomes the accepted definition across the NHS, and the private health sector. This will ensure that all advanced paramedics are clinically competent and that patient safety is not at risk. More advanced paramedic practitioners with extended training could alleviate current pressures on A&E services.

From guidance to practice

Consulting on the guidance closed on 14 August, with an expected publication of 20 December. If the guidance is to be put into practice, the most important step is to introduce additional funding for NHS ambulance services to educate their clinicians through advanced practice programmes. NHS England and clinical commissioning groups would then have to provide funding to deliver specialist and advanced paramedics as part of the core workforce. Additionally, regulation is essential to ensure clinical competency and patient safety.

There is no denying that acute and emergency care is a challenge for all health services. This is largely owing to the fact that as populations age, costs rise, and technological developments extend the limits of health care. However, providing acute and medical care in the community can reduce the need for hospital admissions.

The introduction of more advanced paramedics will meet the increasing and changing needs of patients who access 999 emergency ambulance services. Having a higher proportion of emergency patients assessed and treated in the community will cause a reduction in the number of attendances at emergency departments.

References

Allied Health Professions Medicines Project Team. 2016. Summary of the responses to the public consultation on proposals to introduce independent prescribing by paramedics across the United Kingdom. Leeds: NHS England.

College of Paramedics. 2017. College of Paramedics respond to NICE Consultation [Internet]. Bridgwater: College of Paramedics; [cited 2017 29 August]. Available from https://www.collegeofparamedics.co.uk/news/college-of-paramedics-responds-tonice-consultation.

Dixon S, Mason S, Knowles E. 2009. Is it cost effective to introduce paramedic practitioners for older people to the ambulance service? Results of a cluster randomised controlled trial. Emerg Med J. 26(6):446-51. http://doi.org/ 10.1136/emj.2008.061424.

Mason S, Knowles E, Colwell B et al. 2007. Effectiveness of paramedic practitioners in attending 999 calls from elderly people in the community: cluster randomised controlled trial. BMJ. 335(7626):919. http://doi.org/10.1136/bmj.39343.649097.55

Mason S, Knowles E, Freeman J, Snooks H. 2008. Safety of paramedics with extended skills. Acad Emerg Med. 15(7):607–12. http://doi.org/10.1111/j.1553-2712.2008.00156.x.

Mason S, O’Keeffe C, Knowles E. 2012. A pragmatic quasi-experimental multi-site community intervention trial evaluating the impact of Emergency Care Practitioners in different UK health settings on patient pathways (NEECaP Trial). Emerg MedJ. 29(1):47-53. http://doi.org/10.1136/emj.2010.103572.

National Institute for Health and CareExcellence. 2017. Emergency and acute medical care in over 16s: service delivery and organisation: Draft guidance consultation [GID-CGWAVE0734] [Internet]. London: NICE; [cited 2017 29 August]. Available from https://www.nice.org.uk/guidance/indevelopment/gid-cgwave0734/consultation/html-content.

Taken from Journal of Paramedic Practice, published 8 September 2017.

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Demand on district nursing services leaving staff ‘on their knees,’ says King’s Fund

March 8, 2017 Leave a comment

Adobe Spark (4)A growing gap between capacity and demand in district nursing services has led to staff feeling ‘broken’, ‘exhausted’ and ‘on their knees’, the King’s Fund has said.

A new report (Maybin et al, 2016) published by the think tank has examined the care for older people who receive district nursing services in their own homes. It considered what good-quality care looks like from the perspective of people receiving care, their carers and district nursing staff. This was done by conducting a review of existing policy and research literature, having scoping conversations with national stakeholders, conducting focus groups with senior district nursing staff, and carrying out interviews with patients, carers and staff in three case study sites.

By seeing how patients’ preconceptions of good-quality compared with their actual experiences, the think tank sought to establish what factors support ‘good care’, and figure out what is getting in the way.

Their research indicated that activity has increased significantly over recent years. This applies both to the number of patients seen and the complexity of care provided. From 2005–2014 the number of people living in England has increased by almost 20%, with the most substantial growth seen in the oldest age groups. Additionally, the population aged 85 years and above has increased by just under a third.

It is anticipated that that is set to increase, with the number of people aged 65 years and over expected to rise by almost a half and those aged 85 years and over set to almost double (Mortimer and Green, 2015; Office for National Statistics, 2015). With this increase in age, the likelihood this population will live with chronic disease, multiple health conditions, disability and frailty also rises (Health and Social Care Information Centre, 2014; Oliver et al, 2014).

While demand for services has been increasing, available data on the healthcare workforce suggests a decline in the number of nurses working in community health services over recent years. Additionally, the number working in senior ‘district nurse’ posts has fallen dramatically over a sustained period.

Compromise in quality of care

The result of these pressures is that quality of care is being compromised. Examples highlighted in the report indicate an increasingly task-focused approach to care, staff being rushed and abrupt with patients, reductions in preventive care, visits being postponed and lack of continuity of care. This in turn has caused a deeply negative impact on staff wellbeing, with unmanageable caseloads being increasingly reported. In many cases, staff are leaving the service as a result. Additionally, the King’s Fund has argued that if the ability of district nursing services to deliver appropriate care continues to be undermined, there will be consequences in terms of additional hospital admissions, delayed discharges and dependence on social care.

The King’s Fund have warned that those most likely to be affected by the pressure faced by district nursing staff are often the most vulnerable members of society, who will therefore most likely be affected by cuts in social care and voluntary sectors. They warn that what is more concerning is that this is happening ‘behind closed doors in people’s homes, creating a real danger that serious failures in care could go undetected because they are invisible’ (Maybin et al, 2016).

Recommendations outlined in report

As a result of the issues identified in the report, the King’s Fund have issued the following recommendations as immediate priorities:

Match the stated intention to move care into community settings with greater attention to this service area. Despite intentions by policy makers and regulators to deliver ‘care closer to home’, the direction of resources, monitoring and oversight remains distinctly focused on the hospital sector. The report therefore recommends that community services must be involved in, and central to, the development of new care models and Sustainability and Transformation Plans.

Involve district nursing service leaders in local plans for service redesign. Too often the voice of district nursing service leaders is absent at the system level. The report highlights the valuable role of district nursing and how it is of central importance to the wider health system. The service enhances the health and wellbeing of people living in their own homes, often caring for people with complex and multiple health needs, and helps prevent deteriorations in health and the need for additional services. Therefore now, more than ever, this important but pressured service needs to be part of discussions about future service redesign.

Respond to the issues facing community health and care services, and the needs of people who depend on these, in the round. To address the wide-reaching problems faced by all services, not just district nursing, the report recommends NHS England and Health Education England, together with local commissioners and providers, look in the round at the staffing and resourcing of community health and care services for the older population, taking into account the capacity of people receiving care, their unpaid carers and local communities.

Renew efforts to establish robust national data on capacity and demand in district nursing services. This would include establishing a standard for demand–capacity and workload planning tools in this area, as is currently being undertaken by The Queen’s Nursing Institute and NHS Improvement. The report highlights that the absence of robust national data on activity levels in district nursing services and of a clear dataset on trends in staffing numbers, makes it very difficult to demonstrate, understand and monitor the demand–capacity gap within this service area.

Accelerate the uptake of digital technologies and support implementation. The report argues that adopting new technologies should remain high on the agenda of providers and local service leaders as a strategic area for development, as district nursing stands to benefit significantly from enhanced digital support, if it is designed and works well. Technologies that enable remote working, such as iPads and other tablets, have the potential to improve efficiency and productivity, as well as enhancing quality and safety through timely access to notes at the point of care and supporting communication between professionals.

Develop a meaningful form of oversight for care delivered in people’s own homes, which is sensitive to the unique characteristics of this care. The report stresses the need for national oversight systems to be developed in order for their frameworks to meaningfully capture and reflect care quality. Current national mechanisms of quality assurance and accountability, which are largely designed to assess hospital care, are poorly suited to measuring quality in the community.

Develop a sustainable district nursing workforce. Undoubtedly the most important recommendation, the King’s Fund warns the shortage of suitably trained staff to fill roles in district nursing services is a major cause for concern. Services are increasingly unable to recruit and retain staff. With many of the current district nursing workforce approach retirement age, and others choose to leave due to service pressures, it is understood that this situation will likely worsen.

Conclusions

District nursing services have a key role to play in the national health system, allowing patients to be treated in their own homes and avoid unnecessary hospital admissions. They allow patients to maintain their independence, maintain long-term conditions and manage acute conditions. However, this is only possible through a sustainable workforce. Insufficient staff numbers place unmanageable pressures on the existing workforce as well as other areas of the health service. This report highlights a dissonance between the policy drive to move more care out of hospitals into community settings, and the capacity problems being experienced in district nursing services. It presents a number of recommendations for addressing these issues and calls for the need to develop a robust framework for assessing and assuring the quality of care in the community.

References

Health and Social Care Information Centre (2014) Focus on the health and care of older people. NHS Digital, Leeds. http://digital.nhs.uk/catalogue/PUB14369 (accessed 23 September 2016)

Maybin J, Charles A, Honeyman M (2016) Understanding Quality in District Nursing Services. The King’s Fund, London. http://www.kingsfund.org.uk/publications/quality-district-nursing (accessed 22 September 2016)

Mortimer J, Green M (2015) Briefing: The Health and Care of Older People in England 2015. Age UK, London. http://www.ageuk.org.uk/professional-resources-home/research/reports/care-and-support/the-health-and-care-of-older-people-in-england-2015/ (accessed 22 September 2016)

Office for National Statistics (2015) Population estimates for UK, England and Wales, Northern Ireland: Mid-2014. Office for National Statistics, Newport. http://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/bulletins/annualmidyearpopulationestimates/2015-06-25 (accessed 22 September 2016)

Oliver D, Foot C, Humphries R (2014) Making our health and care systems fit for an ageing population. The King’s Fund, London. http://www.kingsfund.org.uk/publications/making-ourhealth-and-care-systems-fit-ageing-population (accessed 23 September 2016)

Taken from British Journal of Community Nursing, published 3 October 2016.

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Ensuring the district nursing role does not die out

September 4, 2016 Leave a comment

Adobe Spark (2)Recent figures published by the Welsh Government have revealed a 42% reduction in the number of district nurses in Wales between 2009 and 2015 (BBC News, 2016). The number of district nurses has fallen from 712 in 2009 to 412 in 2015, with six of the seven health boards in Wales reporting a reduction.

This follows trends seen in England in recent years, which has reported a 47% reduction in the number of qualified district nursing staff in the past decade (Royal College of Nursing (RCN), 2014). Frequent figures such as these have resulted in a warning from the RCN that district nurses are ‘critically endangered’ and face possible extinction by the end of 2025 (RCN, 2014). Consequently, it has called on the Government to fulfil its commitment to increase the number of community staff to 10000 by 2020.

Origins of district nursing

The district nursing role originated in 1859, when a wealthy Liverpool merchant, William Rathbone, employed a private hospital-trained nurse to care for his dying wife. He was struck by ‘the great comfort and advantage derived from trained nursing, even in a home where everything which unskilled affection could suggest was provided.’ Following the death of his wife, Rathbone set up a training home in Liverpool to give nurses the skills necessary to treat patients in the home.

The title came from the fact that Liverpool was split into 18 districts based on the parish system, so the nurses became known as ‘district nurses’.

There is little research, but a publication from the Department of Health revealed that more than 2.6 million people receive care from district nurses each year, in England and Wales alone, according to statistics gathered nationally (Department of Health, 2004). It is anticipated that this number will only increase.

Due to the increasing elderly population and number of people with long-term conditions, district nurses make a notable contribution to the NHS. Having specially qualified staff who are trained to deliver care to patients in their own homes, should reduce pressures on GP surgeries and emergency departments. However, the shortage of district nurses means many feel they are being pushed to breaking point. Reports of regular additional hours, activities left undone due to lack of time and a desire to leave the job are not uncommon.

The RCN have said the reduced numbers of district nurses has placed extra pressure on GP surgeries and emergency departments. Increases in caseloads from 30 patients to up to 150 means contact time is kept to an absolute minimum. This results in patients not receiving the appropriate care they need and therefore feeling they require further consultation by their GP or at the emergency department.

The future vision of district nurses

In 2009, The Queen’s Nursing Institute (QNI) published its 2020 Vision of the future of district nursing (QNI, 2009). It marked the 150 year anniversary of district nurses and highlighted their role in health care. Fundamentally, the principles of district nursing have changed little in 150 years and consist of ‘better care, closer to home’, ‘patient choice’, ‘integrated care’, and ‘co-production’ (QNI, 2009). As a specialism, district nurses are ‘practitioners, partners and leaders’ of care in the home (QNI, 2009).

Some of the issues identified in the QNI report surrounding district nurses included: ‘loose use of the title, wide variations in pay banding and career structure, reduction in leadership opportunities and lack of recognition of the value of their specialist education’ (QNI, 2009).

It is important to highlight that there is a notable difference between nursing found in clinics, surgeries and other areas of primary care; and that found in patients’ homes. It is for this reason that the district nursing role remains an important part of the NHS.

The British Journal of Community Nursing and the QNI carried out a survey in 2008, gathering information and views from district nurses in England, Wales and Northern Ireland about the state of their specialism. The survey found that 13% of respondents’ employing organisations no longer use the title ‘district nurse’ at all. It also revealed that in those organisations that still use the title, more than 30% do not limit its use to those with a district nurse qualification (QNI, 2009). In some cases, the title was given to team leaders or case managers, with or without the qualification. Additionally, the survey revealed that only 48% of employing organisations continue to require district nursing team leaders to have the district nursing specialist practitioner qualification. Another 19%, who did at the time the report was published, plan to discontinue this requirement.

A follow-up report from the QNI published 5 years after the 2020 Vision, revealed an increase in the level of confusion about job titles, qualifications and roles concerning district nurses (QNI, 2014). As a result, one of the key recommendations of the the report was for a renewed investment in the district nursing specialist practitioner qualification.

Focus surrounding qualifications for district nurses was raised at the most recent RCN Congress, which passed a resolution calling on RCN council to lobby for all district nurse caseload holders to have the relevant specialist practitioner qualification (Ford, 2016). This arose amid concerns over the future of the district nursing role and its protected title. The Forum called for a practitioner who is ‘equipped with skills to manage a role that is highly complex and requires skills in negotiating, coaching, teaching and effective team management’ (Ford, 2016).

The current climate

The situation surrounding the place and role of district nurses within the NHS has gradually changed over the years. For example, it is no longer the sole role to be found delivering nursing care in the home as there are now a multitude of community roles working at different levels. The issue with this is that the meaning attributed to the district nurses’ unique title has eroded somewhat. As mentioned, some employers are using the title without the accompanying specialist qualification, further muddying the waters. District nurses are excellently placed to offer leadership over other health professionals in the home. However, if they have not received adequate training they will struggle to have the strong leadership skills required.

Within Simon Stevens’ Five Year Forward View he called for the introduction of a new care model known as Multispecialty Community Providers. One of the benefits of this model is to allow for the expansion of primary care leadership to include nurses and other community-based professionals. This new way of delivering care and ability to offer a wider scope of services is made possible by allowing the formation of extended group practices as federations, networks or single organisations.

Conclusions

District nurses offer a much-valued service to the NHS through their ability to treat large numbers of people at home, allowing patients to avoid having to go to hospital if they receive the appropriate level of care first-time around. However, this is only possible if the number of district nurses does not continue to fall. The reality is that those still in the role are under increasing pressure, as they find their workloads ever-increasing. The Government must fulfil its commitment to increase the number of community staff, and in particular, the number of district nurses.

Now, more than ever, is the time to reinstate the district nurse.

References

BBC News (2016) Royal College of Nursing concern over fall in district nurses in Wales. BBC News. http://www.bbc.co.uk/news/uk-wales-36828072 (accessed 17 August 2016)

Department of Health (2004) Patient Care in the Community: NHS District Nursing Summary Information for 2003–04, England. The Stationery Office, London. http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4092113.pdf (accessed 17 August 2016)

Ford S (2016) All district nurses ‘should have specialist qualification’. Nursing Times. http://www.nursingtimes.net/news/community/all-district-nurses-should-have-specialist-qualification/7005789.fullarticle (accessed 18 August2016)

Health Education England (2015) District Nursing and General Practice Nursing Service Education and Career Framework. HEE, London. https://hee.nhs.uk/sites/default/files/documents/District%20nursing%20and%20GP%20practice%20nursing%20framework_0.pdf (accessed 17 August 2016)

Royal College of Nursing (2014) District nurses face ‘extinction’ in 2025. RCN, London. https://www2.rcn.org.uk/newsevents/press_releases/uk/district_nurses_face_extinction_in_2025 (accessed 17 August 2016)

The Queen’s Nursing Institute (2009) 2020 Vision: Focusing on the Future of District Nursing. QNI, London. http://www.qni.org.uk/docs/2020_Vision.pdf (accessed 15 August 2016)

The Queen’s Nursing Institute (2014) 2020 Vision Five Years On: Reassessing the Future of District Nursing. http://www.qni.org.uk/docs/2020_Vision_Five_Years_On_Web1.pdf (accessed 15 August 2016)

The Queen’s Nursing Institute, NHS England (2014) Developing a National District Nursing Workforce Planning Framework: A Report Commissioned by NHS England. https://www.england.nhs.uk/wp-content/uploads/2014/05/dn-wfp-report-0414.pdf (accessed 15 August 2016)

Taken from British Journal of Community Nursing, published 2 September 2016.

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The A&E crisis: the burgeoning effect on paramedics

May 23, 2014 Leave a comment

As demands rise and resource pressures grow, NHS emergency services have found themselves placed under increasing pressure. This culminated in the failure of emergency departments to meet national waiting time targets in the early months of this year. The combination of these trends with claims concerning the improved outcomes that are possible by specialist trauma centres, begs the question as to the future of community and primary care services, ambulance services and hospital A&E departments. As a result, the NHS Commissioning Board (NHS England) is reviewing the future configuration of urgent and emergency services in England.

The report, drawn up by the House of Commons Health Committee, suggests that growing demand on A&E departments will make them unsustainable if effective action is not taken quickly to relieve the pressures they face (House of Commons Health Committee (HCHH), 2013a). Concerns were also raised by the committee as to the low numbers of staff in emergency departments, and the role of NHS 111.

Urgent Care Boards
The Government’s response to the pressure in emergency and urgent care revolves around improving local system management in the short term and restructuring care for the medium term. Urgent Care Boards (UCBs) have been created to implement emergency care improvement plans in the local area. However, it was felt by the Committee that UCBs would not be able to implement reforms and influence commissioning. Confusion over a number of features of UCBs, including whether they are voluntary or compulsory, temporary or permanent, established structures or informal meeting groups, has led the committee to conclude that although UCBs have the potential to provide local system management, they currently lack clear direction or executive power (HCHH, 2013a).

NHS 111
NHS 111 is the three-digit telephone service that was introduced earlier this year in an attempt to improve access to NHS urgent care services. At a critical time in the NHS when health economies are facing financial and clinical constraints, its aim is to provide patients with a number they can call when they need help or advice that is not urgent enough to use the conventional 999 service. NHS 111 operates 24 hours a day, 365 days a year, and is free to use from a landline or a mobile.

However, the Health Committee report emphasises the consensus that NHS 111 was instated by ministers prematurely, without any real understanding of the impact that it would have on other parts of the NHS, including emergency and urgent care (HCHH, 2013a). It is felt that because NHS 111 is based around triage by a call handler who is not clinically trained, it does not embody the principle of early assessment by a clinician qualified to a level where they can appropriately quantify the balance and risk. The outcome is a potential for patients to remain dissatisfied or unsure of the instructions they have been given and so remain inclined to attend A&E when it really isn’t necessary.

Despite this, it can be argued that a number of potential benefits could be seen were the ambulance service to assume a more significant role in national 111 provision. Some of the more notable benefits include (HCHH, 2013b):

  • Confidence in a universally recognised professional
  • Experienced and capable function l Whole system effectiveness and value for money
  • Appropriate management of demand across the urgent and emergency care system.

Ambulance services
Along with emergency departments, ambulance services are also being met with ever increasing demands. According to the Association of Ambulance Chief Executives (AACE), in 2011–12, the total number of emergency calls was 8.49 million; this was an increase of 415 487 (5.1%) over 2011–12 (HCHH, 2013b).

Delays in ambulance to A&E handovers or transfers within urgent care are a major everyday issue for ambulance services. Currently, patients have found themselves having to wait up to eight hours in ambulances outside A&E departments. Official figures from eight of England’s ten ambulance trusts show that 3 424 patients waited more than two hours before being handed over to hospital staff during 2012/13, compared with 2 061 patients the year before (Donnelly, 2013).

The AACE recognise that the cause of these delays varies from hospital to hospital but include:

  • Ownership by hospital/health system leaders
  • A&E capacity
  • A&E integration with the rest of the hospital
  • Timeliness of in-Trust escalation
  • Reductions in physical bed capacity within hospitals and the community
  • Attitude and behaviour towards handover delays within the hospital
  • The effectiveness of urgent care pathways keeping demand away from the front door (HCHH, 2013a).

As the paramedic profession takes on broadening responsibilities, ambulance services need to be recognised as a care provider and not simply a transport service for emergency departments. The committee believes that this can be achieved in part through increasing the number of fully qualified paramedics (HCHH, 2013a). By having paramedics who are able to treat patients on-scene, conveyance rates to emergency departments can be reduced, and, therefore, pressure alleviated. In addition, paramedics would be in a position to make the difficult judgement about when to bypass the nearest A&E in favour of specialist units that offer stroke, heart attack, major trauma and specialist children’s services.

In comparison to ambulance technicians, paramedics are trained to make better clinical judgments and administer care more appropriately. It is therefore imperative that ambulance services demonstrate a commitment to establishing a ratio of paramedics to technicians, which ensures that ambulance crews are able to regard conveyance to an emergency department as only one of a range of clinical options open to them (HCHH, 2013b). The report recommends that NHS England undertakes research to establish the precise relationship between more highly-skilled ambulance crews and reduced conveyance rates (HCHH, 2013a). By making full use of the potential of ambulance services, demand pressures in emergency departments could be more easily managed and new care models developed.

References:
Donnelly L (2013) Patients facing eight-hour waits in ambulances outside A&E departments. The Telegraph. http://www.telegraph.co.uk/health/healthnews/10150635/Patients-facing-eight-hour-waits-in-ambulances-outside-AandE-departments.html

House of Commons Health Committee (2013a) Urgent and emergency services: Second report of session 2013–14. Vol 1: Report, together with formal minutes, oral and written evidence. The Stationery Office, London

House of Commons Health Committee (2013b) Written evidence from Association of Ambulance Chief Executives. ES 19. The Stationery Office, London

Taken from Journal of Paramedic Practice, published 2 August 2013.

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