Is now the winter of our discontent? Exploring seasonal pressure on the NHS

My Post (1)Around this time every year, the media is strewn with forewarnings of how winter will put undue strain on the NHS. In a system already struggling to cope, there are concerns that the seasonal pressure pushes services to breaking point. The NHS’s ability to handle yearly increases in demand has led the British Red Cross to go as far as to call it a ‘humanitarian crisis’ (Campbell et al, 2017).

This article will consider the causes of winter pressure on NHS services and how they differ to those experienced throughout the rest of the year. It will explore whether the warnings are genuine or mere hyperbole, and look at some of the ways the NHS attempts to combat these pressures.

Causes of winter pressures

The leading cause of winter pressure is difficult to pinpoint, and can vary from year to year. However, there are a number of recurring contributing factors. While most health problems are not caused by extremes of cold, the weather indelibly has an effect on the number of patients attending accident and emergency (A&E) departments.

Cold weather increases the risk of heart attacks, strokes, respiratory illnesses, flu, falls and other diseases (NHS England, 2013; Public Health England, 2017). Vulnerable people— such as the very young, elderly and those with pre-existing conditions— are those predominantly affected by changes in the weather (National Institute for Health and Care Excellence (NICE), 2015). The effect of winter on the NHS becomes apparent in early December. Performance in A&Es is measured through their ability to meet a 4-hour waiting target. One of the core standards of the NHS Constitution states that a minimum of 95% of patients attending A&E departments in England must be seen, treated and then admitted or discharged in under 4 hours (NHS England, 2015). Breaches of the 4-hour waiting standard result in trusts having to pay penalties (House of Commons Health Committee, 2016).

A&E attendances
Annual attendances at A&E departments have increased. The number of people arriving at major (type 1) A&E departments has seen a 7% rise from 2010 to 2015—from an average of 36 731 attendances per day in August 2010, to 39 220 in August 2015 (Fisher and Dorning, 2016).

Consequently, only 87.9% of patients in type 1 departments were admitted, transferred or discharged within 4 hours in 2015–16 (House of Commons Health Committee, 2016). This is clearly far below the expected standard. The Royal College of Emergency Medicine (2016a) has estimated that the increased attendance over the past 5 years is equivalent to the workload of 10 additional medium sized emergency departments.

Contrary to expectation, the highest number of A&E attendances does not take place in winter. Instead, there is an observable ‘dip’ in visits to A&E around December and January (Fisher and Dornin, 2016). The highest overall attendances are actually in the summer months. The important factor affecting winter pressure is the number of patients subsequently admitted to hospital. The highest proportion of the patient population in summer is under 60 years of age. By contrast, in the winter, it tends to consist of those over 60 years. This spike in the number of more vulnerable, elderly patients is significant because they tend to stay longer in A&E, and are more likely to be readmitted to hospital (Fisher and Dornin, 2016).

Hospital admissions
Like attendances, hospital admissions have also increased. Similarly, they have seen a 7% rise from 13 723 in August 2010 to 14 666 in August 2015 (Fisher and Dornin, 2016). There is a notable ‘peak’ of admissions during the middle of winter (Fisher and Dornin, 2016).

The difference between the proportion of patients admitted is 27.9% in winter, compared with 25.8% in the summer months (Department of Health (DH) et al, 2017).

‘Congestive hospital failure’
The rise in hospital admissions has caused a subsequent decrease in the number of available hospital beds, with the percentage of beds occupied peaking in winter (Fisher and Dornin, 2016). Due to the number of beds available for admission of acutely ill and injured patients continuing to fall over the past 5 years, the UK now has the lowest number of beds per capita in Europe, and England has the lowest number within the UK (Royal College of Emergency Medicine, 2016a). The consequence of limiting bed capacity has been a growth in general and acute bed occupancy from 86.3% in 2010–11, to 91.2% in 2015–16 (Royal College of Emergency Medicine, 2016b).

A lack of available beds reduces flow through A&Es as it slows the accommodation of new attendances (Royal College of Emergency Medicine, 2016a). This in turn affects the ability of ambulance services to off-load patients—an issue known as ‘congestive hospital failure’ (NHS England, 2013).

Another factor influencing occupancy rates is delayed transfer of care, which leaves systems less resilient to operational pressures. Unnecessary delay in discharging patients who no longer need to be in hospital led to 1.15 million bed days being lost in acute hospitals during 2015 (National Audit Office, 2016).

Combatting pressures

To help combat winter pressures, the NHS conducts strategic planning each year. For the 2017/18 winter, formal planning began at its earliest time yet in July (Philip, 2017). Local plans were submitted in September covering resilience arrangements from the start of December up to Easter 2018.

As part of this preparation, Public Health England (2017) publishes a Cold Weather Plan every year to help protect the population against harm from cold weather. A mixture of past experience and forward-planning will help build future resilience. Below are some of the key methods of combatting pressure.

Best use of ambulance services
An expansion of the ‘hear and treat’ and ‘see and treat’ services provided by ambulance services can help alleviate demand on A&E departments. ‘Hear and treat’ services refer to 999 calls that are successfully completed without dispatching an ambulance vehicle response. Examples of this include over-the-phone advice, instructions for self-care, or referral to other urgent services (Urgent and Emergency Care Review Programme Team, 2015).

‘See and treat’ services refer to a model of care where a patient is clinically assessed at scene, before being provided with immediate treatment and subsequent discharge and/or referral (Urgent and Emergency Care Review Programme Team, 2015). By avoiding taking patients unnecessarily to A&E, they can be referred to more appropriate services that better fit the patient’s needs, or further support can be provided at home or in a community setting. ‘Hear and treat’ and ‘see and treat’ services now cover 3.5 million people (NHS England, 2017b).

This winter will see the full rollout of phase two of the Ambulance Response Programme, with the introduction of new call standards that accurately reflect the type and urgency of care needed by patients (Quaile, 2017). Along with the new dispatch on disposition system, giving call handlers more time to triage 999 calls, it is hoped that many patients can avoid being taken unnecessarily to A&Es.

Boosting flu vaccinations
Flu outbreaks within health services can be crippling and are a genuine concern each winter. Last year, 49% of NHS staff were vaccinated against the influenza virus and, this year, the number of vaccinated staff has been raised to 63% (NHS England, 2017b).

Additionally, free flu jabs will be provided to hundreds of thousands of care-home staff at a cost of up to £10 million; and numbers of vaccinations for young children and vulnerable people will be increased (NHS England, 2017a). Being vaccinated is the best way to prevent the spread of flu infection and reduce avoidable deaths. As it is possible to have flu without showing any symptoms, health professionals could find themselves working with flu but not realising it. It is essential they are vaccinated to avoid spreading the illness to vulnerable people.

Increasing funding
The spring budget announced an additional £100 million to support improvements in emergency departments through the implementation of a primary-care streaming model (Philip, 2017). Here, patients are streamed away from highly pressured emergency departments, to co-located GP-led primary care services, for conditions more suited to assessment and treatment in primary care (NHS Improvement, 2017).

Achieving ‘good’ patient flow
According to Monitor (2015), improving patient flow through hospital departments other than A&E is ‘the most important systemic means’ of avoiding sharp declines in A&E performance during winter. Health systems that have better patient flow are much better at coping with external pressures than those who don’t (NHS Improvement, 2017). Within ambulance services, good patient flow is seen as the handing over of a patient to an emergency department within 15 minutes of arriving (NHS Improvement, 2017).

My Post (2)Encouraging self-care
Further promotion of self-care is essential to reducing demand on health services. Giving people the confidence and information to look after themselves can help prevent ill health and reduce pressure (British Medical Association, 2016). However, for this to work, support needs to be easily accessible.

Improving housing conditions
Housing conditions for vulnerable people play an important part in the number of excess winter deaths and illnesses. In the coldest 10% of homes, the death rate rises approximately 2.8% for every degree Celsius drop in the outside temperature (NICE, 2015).

In England, there is a relatively sharp increase in the risk of death when outdoor temperatures fall to around 6°C (NICE, 2015). Improving heating and insulation for vulnerable people is therefore highly important for reducing avoidable illness or death.

Addressing growing GP demand
General practice is on the brink of crisis as a result of inadequate resourcing, an insufficient workforce, and an unsustainable workload (British Medical Association, 2016). The number of GP consultations in England rose from 303 million in 2008/9 to 361 million in 2013/14 (Royal College of General Practitioners, 2015). However, despite this 19% increase in demand, there has been no change in resourcing and staffing, putting undue strain on GP services (British Medical Association, 2016).

Increased funding in social care
Social care has been struck by considerable funding cuts in recent years, creating a knock-on effect on the number of people receiving services.

There were 500 000 fewer people who accessed social care in 2013/14 compared to 2008/9 (Franklin, 2015). This is despite an increasing ageing population, where the number of over-85s will double over the next two decades. It is also anticipated that adults with a learning disability will increase by at least a third (Local Government Association, 2016).

The cut of £5 billion in local authority social care budgets over the last 5 years has placed significant pressure on services (Local Government Association, 2016). Delays in arranging community nursing or social care has a considerable impact on delayed transfers, with 60% of trusts believing the increase in delayed transfers of care is owing to reductions in social care capacity (Monitor, 2015).

Conclusion
This article has sought to explain the reasons behind additional pressures on health services brought on by the winter season. While attendances at A&E are lower during the winter, the number of hospital admissions of vulnerable patient groups rises, largely because of seasonal illnesses such as flu and norovirus. This causes a reduction in the number of beds available and reduced patient flow within hospitals.

To combat these pressures, longer term investments are needed to address the insufficient workforce, lack of social care, and demand on primary care services. Although there has been additional investment in vaccination against flu; primary-care streaming; and resilience funding for ambulance services for this winter; it is unclear what impact—if any—this will have on health services.

References

British Medical Association. Beating the effects of winter pressures: Briefing paper. 2016; London: BMA

Campbell D, Morris S, Marsh S. NHS faces ‘humanitarian crisis’ as demand rises, British Red Cross warns [Internet]. London: The Guardian; 2017. [cited 2017 Oct 23]. Available from http://tinyurl.com/y73vemzg

Department of Health, NHS England, NHS Improvement. Written evidence submitted by the Department of Health, NHS England and NHS Improvement (WIP0035) [Internet]. 2017. [cited 2017 Oct 23]. Available from http:// tinyurl.com/y7vlmu5r

Fisher E, Dorning H. Winter pressures: what’s going on behind the scenes? London: Quality Watch; 2016

Franklin B. The end of formal adult social care: A provocation by the ILC-UK. 2015; London: ILC-UK

House of Commons Health Committee. Winter pressure in accident and emergency departments: Third Report of Session 2016–17. 2016; London: The Stationery Office

Local Government Association. Adult social care funding: 2016 state of the nation report. 2016; London: LGC

Monitor. A&E delays: why did patients wait longer last winter? [Internet]. 2015. [cited 2017 Oct 23]. Available from http://tinyurl.com/ ofw2uv3

National Audit Office. Discharging older patients from hospital [Internet]. 2016. [cited 2017 Oct 23]. Available from http://tinyurl.com/hnyuy2p

National Institute for Health and Care Excellence. Excess winter deaths and illness and the health risks associated with cold homes. Clinical Guideline 6. 2015; London: NICE

NHS England. NHS leaders unveil action to boost flu vaccination and manage winter pressures. [Internet]. 2017a. [cited 2017 Oct 21]. Available from http://tinyurl.com/ycp5k8er

NHS England. The Handbook to the NHS Constitution. 2015; London: The Stationery Office

NHS England. Understanding Winter Pressures in A&E Departments [Internet]. 2013. [cited 2017 Oct 21]. Available from http://tinyurl.com/ yblaeduc

NHS England. Urgent and emergency care [Internet]. 2017b. [cited 2017 Oct 21]. Available from http://tinyurl.com/y9dctbsp

NHS Improvement. National priorities for acute hospitals 2017. Good practice guide: Focus on improving patient flow [Internet]. 2017. [cited 2017 Oct 23]. Available from http://tinyurl. com/y7t6mfam

Philip P. Letter to all CCGs and providers regarding planning for winter 2017/18, and other operational priorities [Internet]. 2017. [cited 2017 Oct 22]. Available from http:// tinyurl.com/y82kelxe

Public Health England. The Cold Weather Plan for England: Protecting health and reducing harm from cold weather. 2017; London: The Stationery Office

Quaile A. What’s next for England’s ambulance services? J Paramed Pract. 2017;9(10): 443-444

Royal College of Emergency Medicine. Why does winter in A&E get worse every year? 2016a; London: The Royal College of Emergency Medicine

Royal College of Emergency Medicine. Written evidence submitted on behalf of the Royal College of Emergency Medicine (WIP009) [Internet]. 2016b. [cited 2017 Oct 23].Available from http://tinyurl.com/y8naucxs

Royal College of General Practitioners. Patient safety implications of general practice workload. 2015; London: RCGP

Urgent and Emergency Care Review Programme Team. Transforming urgent and emergency care services in England: Clinical models for ambulance services. 2015; Leeds: NHS England

Taken from Journal of Paramedic Practice, published November 2017.

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Working in the early days of the NHS

Adobe Spark‘It was to be a big wide world but I wanted to be part of that.’ Ethel Armstrong was 18 when health secretary Aneurin Bevan launched the NHS on July 5 1948. Now 87, Ethel went on to enjoy an illustrious career within the health service. Spanning over four decades, she worked across the country in various roles, mainly in radiodiagnosis and in nursing. After retiring in 1989/90, she has continued to support the NHS through two charities, the NHS Retirement Fellowship (nhsrf.org.uk/) and Cavell Nurses’ Trust (www.cavellnursestrust.org/), making it a remarkable 70 years of unbroken service. They would love to hear from retirees from any disciplines who are now retired or coming up to retirement.

Born in Durham, Ethel began her career as a cadet. The cadet scheme was aimed at 17 year olds who didn’t know what area of the health service they wanted to get into. It offered them the chance to work in different fields before choosing a career path. She was encouraged to join by her headmaster, who told her about a ‘new scheme coming, with brand new free care for everybody from cradle to the grave.’ Feeling she had the requirements necessary for the role, he put her name forward for the scheme.

Ethel had wanted to become a doctor or dentist, but, like many in the years following the Second World War, was not in a position to pay to study for a qualification. ‘They didn’t have grants in those days,’ she says. ‘If your parents couldn’t afford to send you to university then I’m afraid you had to do it the hard way.’

Before the NHS

In the days before the NHS, healthcare provision in the UK was notably different. ‘It was a different ball game altogether; your doctor did absolutely everything,’ says Ethel. ‘The doctor’s man came round and he collected 4p for a husband and wife, and a penny for each child, so that they were put on that GP’s books.’

One of the differences Ethel recalls was the cost for the delivery of a child, which she says was one shilling and sixpence. This meant that, for those lucky few who were born on July 5 1948, their parents were saved the fee. ‘If they were born a day earlier their mothers would have had to pay one and six, but because [there was now an] NHS they got it free,’ she says.

The early years

Ethel’s first step into health care was at a large mental health hospital in Newcastle in 1947, where she worked on rotation in a number of departments. When the NHS was launched in 1948 she began studying radiodiagnosis at the city’s Royal Victoria Infirmary, which ‘wasn’t as posh as it is now’.

‘The corridors had black and white tiles, there were wooden forms all the way along and patients brought their sandwiches,’ she says. ‘You were there for half a day and you saw a medical man or you saw a surgeon.’

Qualifying in 1951, she emphasises how, in the early days of the NHS, there was a strict adherence to appearance and discipline.

‘You were taught protocol, code of conduct and dress code, and that was important,’ she says. ‘You knew who you could speak to and how you could speak to them. And that now seems to be sometimes lacking.

‘[It] made your day if the consultant stopped and said “good morning”. But most times, you were taught from a very early age that if a consultant was coming up the corridor you waited, and if there was a door to open, you opened the door. That was the discipline in 1948,’ she adds.

An evolving health service

Ethel entered the world of nursing and midwifery several years after beginning her career, but ended up returning to radiodiagnostics, her preferred area of health care. Throughout her time in the NHS she saw considerable change and advancements in technology.

‘I’ve seen more changes than you can shake a stick at,’ she says. ‘The important ones are the ones that improve lives—the other ones you just forget about, but advances in maternity services and knee replacements, hip replacements, have been tremendous.’

Next year the NHS will celebrate its 70th anniversary. Since its inception it has continued to grow. It now employs more than 1.5 million people and treats over 1 million patients in England every 36  hours. However, an ageing population has meant it is finding it increasingly difficult to meet patient demand, and many have called it unsustainable. For Ethel, though, there will always be an NHS.

‘The NHS will definitely still be here in 70 years,’ she says. ‘It will be a different format. I think you’ll be given a do-it-yourself box, everybody will have to go on a computer course, you will all have to know how to access this, that and the other. It will be, I’m quite sure, a high-tech world.

‘I connect with nurses and midwives, as well other NHS workers. My passion and commitment since retirement in 1990 is continuous, totalling a staggering 70 years. I have been overwhelmed by requests for media coverage and I have been asked if I will do it all again next year. My answer is an emphatic YES as I support every one of the workforce past and present.’

Taken from British Journal of Nursing, published October 2017.

Do advanced paramedics have a role as independent prescribers?

adobe-spark-3The journey regarding the proposal to introduce independent prescribing by advanced paramedic practitioners has been one focused on patient safety and a strong case for need. The challenge for the profession has been to ensure it’s positioned to respond to any concerns, and that any changes to the law allowing prescribing are made on the basis that patients will benefit.

Ministerial approval to take the proposal forward to the public consultation phase was granted by NHS England on 15 August 2014. The NHS England Allied Health Professions Medicines Project Team, in partnership with the College of Paramedics, developed a case of need for the proposal based on improving quality of care for patients. These improvements related to safety, clinical outcomes and experience, as well as the efficiency of service delivery, and value for money. Approval of the case of need was received from NHS England’s medical and nursing senior management teams in May 2014, and from the Department of Health non-medical prescribing board in July 2014.

Alongside the paramedic proposal, NHS England consulted on proposals to allow three other allied health professions to be able to prescribe or supply and administer medicines, as appropriate for their patients. These proposals were for independent prescribing by radiographers; supplementary prescribing by dietitians; and the use of exemptions within the Human Medicines Regulations 2012 by orthoptists.

At the time, Suzanne Rastrick, Chief Allied Health Professions Officer at NHS England, said:

‘Our proposals will allow patients to get the medicines they need without delay, instead of having to make separate appointments to see their doctor or GP.

‘Breaking down barriers in how care is provided between different parts of the NHS is key to the vision set out in the NHS Five Year Forward View.

‘Extension of prescribing and supply mechanisms for these four professions creates a more flexible workforce, able to innovate to provide services that are more responsive to the needs of patients, and reduce demand in other parts of the healthcare system.’

The public consultation opened on 26 February 2015 and ran for 12 weeks. As well as consulting on proposals for advanced paramedics to become independent prescribers of medicines across the UK, it also proposed that consideration be given to paramedic independent prescribers being allowed to mix licensed medicines prior to administration, and prescribe independently from a restricted list of controlled drugs. Anyone was welcome to respond, and feedback was received from members of the public, patients/patient representative groups, carers, voluntary organisations, health-care providers, commissioners, doctors, pharmacists, allied health professionals, nurses, regulators, non-medical prescribers and the Royal Colleges, as well as other representative bodies.

Why independent prescribing was not recommended

Following the close of the consultation, responses received were collated and analysed. The responses were considered by both the Commission on Human Medicines (CHM) and Medicines and Healthcare Products Regulatory Agency (MHRA), who felt unable to recommend independent prescribing for advanced paramedics at present.

The reasons for this decision were concerns over the wide range of conditions encountered by advanced paramedics and whether they could demonstrate evidence of adequate training and competency to diagnose the conditions that will be prescribed for. Additionally, there were notable concerns over the definition of an advanced paramedic practitioner, as this appears to vary between allied health professionals.

As a result, The CHM felt that independent prescribing might represent a risk to patient safety; for example, and in context with the lack of available evidence of competency at the time, if the wrong diagnosis was made and an inappropriate treatment was prescribed. They also felt that some of the examples cited to demonstrate a need for independent prescribing were not sufficiently robust.

Considering the possibility of independent prescribing

The College of Paramedics expressed disappointment that the CHM was unable to recommend independent prescribing for advanced paramedics at the present time, and has said it will continue its support and commitment to work with the project, and with NHS England this year to address the very legitimate comments made by the CHM. The college also said it would give regular updates to its members on the progress of the work.

Speaking on the possible future for independent prescribing by advanced paramedics, Andy Collen, medicines and prescribing project lead for the College of Paramedics, said:

‘We absolutely think that advanced paramedics have got a role as independent prescribers. The journey for any profession to undertake independent prescribing has to be done so with absolute rigour and consideration for patient safety. We need to provide reassurance that what is being proposed is going to benefit patients completely and that any risks are understood. Although it is disappointing, we absolutely welcome the feedback from CHM and we are continuing to work to answer the concerns the CHM have, and that is being supported by NHS England.’

Gerry Egan, chief executive officer of the College of Paramedics, said:

‘The College has a clear definition of the advanced paramedic role in terms of competencies and education and is working to make this the accepted definition both across the NHS and in the private health sector.

‘The College have no doubts advanced paramedics will deliver a massive benefit to patients in terms of delivering the right care at the right place and at the right time by the use of safe independent prescribing as part of integrated care systems.

‘The College remains totally committed to the proposal to introduce independent prescribing by advanced paramedics and looks forward to continuing supporting NHS England.’

Taken from Nurse Prescribing, published 9 September 2016.

Royal Pharmaceutical Society updates prescribing competency framework

Adobe Spark (1)The Royal Pharmaceutical Society (RPS, 2016) has published an update to the Competency Framework for all Prescribers to ensure health professionals prescribe safely and effectively.

Originally published in 2012, the framework was developed to offer a common set of competencies for prescribing, regardless of professional background. As a result, it is relevant to all prescribers, including doctors, pharmacists, nurses, dentists, physiotherapists, optometrists, radiographers, podiatrists and dietitians. However, the framework should be contextualised to reflect different areas of practice and levels of expertise.

Ash Soni, President of the RPS, said:

‘Both the number of medicines prescribed and the complexity of medicine regimens are increasing. The challenges associated with prescribing the right medicines and supporting patients to use them effectively should not be underestimated.

‘There’s lots of evidence to show that much needs to be done to improve the way we prescribe and support patients in effective medicines use. This guide will be invaluable and I’m delighted the RPS has coordinated the update.’

The initial framework was published by the National Prescribing Centre and the National Institute for Health and Care Excellence (NICE). For the update, the RPS was approached by NICE and Health Education England to carry out the work on behalf of all prescribing professions. Additionally, the RPS was asked to ensure the framework had UK-wide applicability.

A project steering group of prescribers across all professions and patients updated the framework. This involved a 6-week consultation of the draft policy, where hundreds of organisations and individuals responded.

The framework has been endorsed by the UK’s Chief Pharmaceutical Officers—Keith Ridge, Rose Marie Parr, Andrew Evans and Mark Timoney—who said:

‘The single competency framework provides a means for all prescribers to become equipped to support patients to achieve the best outcomes from their medicines.

‘This update will ensure individuals can continue to benefit from access to resources which help them continually improve their practice and work more effectively.

‘We commend the updated framework and encourage prescribers, professional bodies, education providers and regulators to use it to support their role in delivering safe and effective care.’

How the competencies are separated

The framework comprises 10 competencies split into two areas: the consultation and prescribing governance. Within each of these competency areas, statements describe the activity or outcomes that prescribers should be able to demonstrate.

The consultation

The first competency concerns assessing the patient. It promotes taking an appropriate medical, social and medication history, before undertaking an appropriate clinical assessment.

The second competency involves the prescriber considering the options for the patient. This includes both non-pharmacological and pharmacological approaches to treatment, and weighing up the risks and benefits to the patient of taking medicine.

The third competency is about reaching a shared decision with the patient/carer, so the patient/carer can make informed choices and agree on a plan that respects the patient’s preferences.

The fourth competency is the prescribing itself. The framework states the medicine should be prescribed only with ‘adequate, up-to-date awareness of its actions, indications, dose, contraindications, interactions, cautions, and unwanted effects.’ Where appropriate, medicines should be prescribed within relevant frameworks, such as local formularies or care pathways.

The fifth competency concerns providing information to the patient/carer about their medicines. This includes what the medicine is for, how to use it, possible unwanted effects and how to report them, and expected duration of treatment.

The sixth and final competency in the area of consultation is monitoring and reviewing. Here the prescriber should establish and maintain a plan for reviewing the patient’s treatment. The effectiveness of treatment and potential unwanted effects should be monitored.

Prescribing governance

The seventh competency, and first under the area of prescribing governance, concerns prescribing safely. It highlights that the prescriber should prescribe within their own scope of practice and recognise the limits of their own knowledge and skill.

The eighth competency comprises prescribing professionally, and ensuring the prescriber maintains confidence and competence to prescribe. This includes accepting personal responsibility for prescribing and understanding the legal and ethical implications.

The ninth competency focuses on improving prescribing practice through reflection. It also stresses the importance of acting on feedback and discussion.

The tenth and final competency involves prescribing as part of a multidisciplinary team to ensure continuity of care across care settings. Part of this concerns establishing relationships with other professionals based on understanding, trust and respect.

Putting the framework into practice

The framework can be used for a variety of reasons by prescribers to help them improve their performance and work more effectively. The following examples are highlighted in the framework:

  • To inform the design and delivery of education programmes; for example, through validation of educational sessions (including rationale for need) and as a framework to structure learning and assessment
  • To help health professionals prepare to prescribe and provide the basis for ongoing education and development programmes, continuous professional development and revalidation processes. For example, use as a framework for a portfolio to demonstrate competency in prescribing
  • To help prescribers identify strengths and areas for development through self-assessment, appraisal and as a way of structuring feedback from colleagues
  • To inform the development of education curricula and relevant accreditation of prescribing programmes for all prescribing professions
  • To provide professional organisations or specialist groups with a basis for the development of levels of prescribing competency; for example, from recently qualified prescriber through to advanced prescriber
  • To stimulate discussions around prescribing competencies and multidisciplinary skill mix at an organisational level
  • To inform organisational recruitment processes to help frame questions and benchmark candidates’prescribing experience
  • To inform the development of organisational systems and processes that support safe effective prescribing; for example, local clinical governance frameworks.

The RPS is liaising with the professional bodies and organisations of the other prescribing professions to encourage uptake of the framework, which will be reviewed again in July 2020.

References

Royal Pharmaceutical Society (2016) A Competency Framework for all Prescribers. http://www.rpharms.com/support-pdfs/prescribing-competencyframework.pdf (accessed 1 August 2016)

Taken from Nurse Prescribing, published 12 August 2016.

Pay survey reveals two thirds of paramedics considering leaving ambulance service

Adobe Spark (5)Two thirds of staff say they will consider leaving the ambulance service if a change to the pay banding of paramedics is not made, according to a survey carried out by the Journal of Paramedic Practice.

An online poll completed by 1084 paramedics has revealed that 67% will consider leaving the ambulance service if the Government continues to fall back on its 2015 promise of reviewing the banding system to recognise the skill set of paramedics. Additionally, 87% felt the Government has misled ambulance service staff over promises for pay.

One respondent said: ‘Increased pressure to use alternative pathways, treat at home, discharge on scene. Increased level of assessment and treatment options, together with increased expectation of qualifications and study, but for no extra pay? Ridiculous.’

Another said: ‘Several of my colleagues and friends are struggling to pay their home bills and have left the job for better paying roles in the Arab states.’

Commenting on the findings, Gerry Egan, chief executive officer for the College of Paramedics, said:

‘Since its establishment, the College of Paramedics has worked hard to develop the paramedic profession in the interests of providing the best possible care to patients and to ensure that paramedics receive due recognition for the service they give to society.

‘This combined with the increased reliance on paramedics by the health system, which has come about for a number of reasons, means that there has been a continuous increase in the expectations of the range and quality of services that paramedics provide. So it comes as no surprise that the results of the Journal of Paramedic Practice’s survey are similar to a survey conducted by the College of Paramedics last year.

In 2014, paramedics were among the thousands of health professionals who took to the picket line in the first NHS strike over pay in 32 years.

The dispute came as ministers in England awarded NHS staff a 1% increase in pay, but only for those without automatic progression-in-the-job rises.

Despite the independent NHS Pay Review Body recommending a 1% rise across all pay scales, ministers claimed this was an ‘unaffordable’ cost.

In a desperate effort to resolve the pay dispute of 2014/15, the Secretary of State for Health, Jeremy Hunt, agreed to a number of commitments to ambulance staff, including a review of the banding system.

Current vacancy rates for the paramedic profession are at 10%. This represents 1 250 vacancies out of a total workforce of 12 500. It is believed that these high vacancy rates are due to changes made to the healthcare system in recent years. This includes a shift in focus to treat patients at home rather than conveying them to A&E, as well as a change in the nature and volume of job opportunities for paramedics.

Almost all respondents (93%) of the survey believed that the current scope of practice of paramedics is changing as a result of increased skills and competencies. Additionally, 94% felt band 6 of the Agenda for Change pay scale was a more appropriate pay band due to the level of responsibility and autonomy practised within the paramedic role, including triage, referrals, and decisions around non conveyance. Overall, 96% believed their pay did not reflect their responsibilities.

However, not all believed that current pay for paramedics has contributed to increasing vacancy rates and the number of people leaving the profession.

‘I disagree that this would be a reason for paramedics leaving,’ said one respondent. ‘With the role having changed so much, I believe that our advanced practice colleagues (paramedic practitioner/emergency care practitioner) are leaving to work in hospitals. There is potential to earn more money, better chance of a break, and better working conditions. I disagree that pay alone is a reason staff are leaving.’

According to Egan, the significance behind the figures for those considering leaving the profession may be unclear:

‘The responses regarding those intending to leave their positions as paramedics may be blurred somewhat between those intending to leave ambulance service employers and those who might leave the profession,’ he said. ‘It is a well-known fact that many paramedics are leaving ambulance services to take up opportunities in walk-in centres, minor injuries units and the like.’

A large number of respondents felt that it was work pressures and stress that have contributed most to the number of paramedics leaving the ambulance service:

One respondent said: ‘I don’t think pay is a factor in staff leaving. Lack of retention [is] more likely due to increased workloads, poor culture and public expectation.’

Another respondent said: ‘There have been some paramedics with MSc or BSc that have left to find better paid jobs. But the majority of paramedics leaving the profession is due to the increasing workload and the undertaking of urgent care alongside emergency work. Demand, stress and pressure are why paramedics are leaving, not money.’

Stress and burnout remain an undeniable issue facing ambulance staff, with paramedics in England taking 41 243 days off in 2014 as a result of stress-related illnesses. This has had an inevitable impact on those choosing to leave the ambulance service. Only a handful of ambulance services have agreed to pay paramedics Agenda for Change band 6 in the hope of recruiting and retaining paramedics .

Another significant finding was that 66% of respondents believed there are no adequate opportunities for career progression.

A common consensus was that progression only came in the form of management positions, with few opportunities for promotion in a clinical capacity.

One respondent said: ‘There are a number of areas within the paramedic profession to progress to, such as critical care roles or minor health roles, or management; however, these areas still do not have the same pay scale as other health sectors, meaning progression, while increasing skills, does not increase pay, therefore [it] is seen as a way to gain skills in order to leave to a sector with increased pay.’

However, this was not felt by all, with one respondent highlighting the work that the College of Paramedics has done to outline career pathways:

‘The College of Paramedics (and South East Coast Ambulance NHS Foundation Trust) has done a lot to develop career pathways. Integration of the out-of-hours providers and the ambulance service would provide even more opportunity for paramedics to progress as well as improving the response times for patients.’

Commenting on the suggestion there are insufficient career progression opportunities within the paramedic profession, Egan said: ‘The College would argue that its career framework sets out the roadmap for career progression and the shortage of opportunities may be a problem to be addressed by the main employers of paramedics.’

As a result of the Government not reviewing the banding system for paramedics, the unions UNISON, GMB and Unite conducted consultative ballots of ambulance staff. The responses indicated that ambulance staff in England will take part in industrial action, including strike action, if the Government continues to not deliver in its promises over pay.

Each union is reporting their ballot results to members, before consulting over the next steps.

Results published by Unite show that 66% of members voted yes to taking strike action and action short of strike action, with a turnout of 31%.

Results from the other two unions have not yet been made public.

A joint statement issued by the unions said:

‘We are clear that ambulance staff have waited for 12 months and are not going to wait longer. If possible, we would also like to avoid a dispute, and the disruption that strike action will bring, however we know that ambulance staff are not prepared to wait indefinitely.

‘We will be calling on Government to make real commitments to ambulance staff, within clear timescales. If there is a genuine will to avert a dispute then we will pause the move to a full industrial action ballot while we hold constructive discussions.’

While the National Ambulance Strategic Partnership Forum have made a formal request to the National Job Evaluation Group to look at the National Job Evaluation paramedic profile, only a handful of ambulance services have agreed to pay paramedics Agenda for Change band 6 in the hope of recruiting and retaining paramedics. This includes East of England Ambulance Service NHS Trust, West Midlands Ambulance Service NHS Foundation Trust, Yorkshire Ambulance Service NHS Trust. There is currently no indication that other services will follow suit.

Taken from Journal of Paramedic Practice, published 1 July 2016.

Ambulance staff contemplate suicide due to poor mental health

Project M (1)‘It started to manifest itself after a failed resuscitation attempt on a child several years ago. While there were low-level symptoms over the years, and there were certain calls that would affect me more than others, there was much more severe recurrence after witnessing the aftermath of a plane crash over a year ago.’

Aryeh Myers, 39, is a paramedic for Magen David Adom, Israel’s national ambulance service. Before that he worked for London Ambulance Service NHS Trust for almost 10 years, as both an emergency medical technician (EMT) and paramedic. He was diagnosed with post-traumatic stress disorder (PTSD) just over a year ago.

Myers is one of an alarming number of paramedics whose mental health has suffered directly as a result of working for the ambulance service.

Recent figures published by mental health charity Mind revealed a third of ambulance staff surveyed contemplated taking their own lives due to stress and poor mental health. The results, taken from the responses of 1 600 emergency services staff and volunteers, including 308 in the ambulance service, also showed that 67% of ambulance staff contemplated leaving their job or voluntary role because of stress or poor mental health. A huge 93% reported experiencing stress, low mood and poor mental health at some point while working for the emergency services.

The figures also highlighted how 57% of ambulance staff took time off due to stress, low mood or poor mental health. These results reaffirm those published by The Observer that revealed over 40 000 days were lost by ambulance staff in 2014 due to mental health problems.

For Myers, he recalls how he took a month off work to begin treatment, including several sessions with a counsellor who taught him how to recognise triggers, how to partially ward them off, and particularly how to deal with the thoughts and reactions that those triggers bring.

‘It helped to a certain degree,’ he says. ‘At least I was able to go back to work. But there is, from what I’ve experienced, no way to completely get rid of PTSD, and certainly not if you continue working in the field where it was caused in the first place.’

Blue Light Programme

In October 2014, Mind was awarded LIBOR funding to deliver a programme to provide mental health support for emergency services staff and volunteers from police, fire, ambulance and search and rescue services across England up until 31 March 2016.

The Blue Light Programme focused on five main areas: tackling stigma and discrimination, embedding workplace wellbeing, building resilience of staff, providing information and support, and improving support pathways.

So far the programme has seen 250 000 information resources disseminated, 5 000 managers participate in line manager training, over 400 emergency services staff register to be ‘Blue Light Champions’, and 54 blue light employers and 9 national associations sign the Blue Light Time to Change pledge—a commitment to raising awareness of mental health, tackling stigma and helping enable staff and volunteers to talk more openly about their mental health at work. Currently, all ambulance services in England except East of England Ambulance Service NHS Trust have signed the pledge.

Funds have been allocated for Mind to continue to deliver the programme on a smaller scale throughout 2016/17.

Esmail Rifai, 50, is a clinical safety officer for North West Ambulance Service NHS Trust, who recently returned to work following a long period of work-related anxiety and depression. He lost a work colleague and friend to suicide.

‘My colleague taking his own life had a devastating effect on me at a time when I was coming to terms with my own mental health,’ he says.

‘At work I often take on more than time permits, which inevitably takes its toll and ultimately ends up with my own mental health deteriorating.’

Rifai is a ‘Blue Light Champion’ and has found the experience helpful in coming to terms with his own mental health issues. ‘Being involved with the Blue Light Programme has also given me some solace,’ he says. ‘Knowing that I’m helping others in itself makes me feel good—a sense of achievement.’

Exposure to shocking events

Project M (3)Dan Farnworth is an EMT for North West Ambulance Service NHS Trust who has also suffered from PTSD.

‘My mental health issues started about a year and a half ago,’ he says. ‘We went to a job that involved child abuse. It was awful. We did everything that we could, but unfortunately we weren’t able to save the child.’

While Farnworth understandably felt low after the job, it wasn’t until 24 hours later that he found himself unable to shake the image of the child from his head.

‘At work I wasn’t acting like myself anymore; I wasn’t socialising as much with colleagues, and generally not interacting with people.’

In addition to his work, he found the event had begun to affect his life at home as well.

‘It made me a grumpier person, and my patience was a lot shorter. It even started to affect my sleep, and I found myself having nightmares about it.

‘I’d often find myself just sat there, not really doing anything but thinking about the job, and thinking about whether there was anything else I could have done.’

The nature of work undertaken by ambulance services means there are times when paramedics find themselves turning up at the scene of a shocking or upsetting event.

‘As a paramedic there is no way to avoid seeing sights that are difficult,’ says Myers. ‘It may be one shocking call, or it may be a build up over time, but I believe we are all affected in some way by the things we see, by the emotion we experience but are forced to contain while dealing with our job. Showing any sign of emotion is still perceived as a weakness rather than an outlet, and this is one of the things that needs to change.’

Kevin Sibley is an EMT for East of England Ambulance Service NHS Trust who served 8 years within the army. A year of that time was spent in Northern Ireland where he witnessed a number of harrowing events. He remains unconvinced at the prevalence of mental health problems suffered by ambulance staff.

‘I have known people who have left the ambo service and have come back 6 months later after querying suffering mental problems,’ he says.

‘Unfortunately I think lots of people use the mental health card in the ambo. PTSD in the military is not an excuse, it’s because your mates who will die for you are killed in a horrible situation. Unfortunately I can’t compare this to the ambo service as we join to help people in road traffic collisions (RTC) etc. You [can] walk in to a hanging, RTC or decapitation.’

Sibley is of the opinion that some paramedics are quick to associate distressing events with potential mental health issues, with some reaching for the latest buzz word to explain how they are feeling.

‘I don’t mean to belittle people with issues but we were unwell,’ he says. ‘Not dealing with it, then stress, then depression. People looked for a new thing, a new name, and grabbed PTSD.’

Support for ambulance staff

Currently, ambulance services have internal debriefing support services, and through occupational health staff have access to professional counselling services. Additionally, support is provided to ambulance service staff and their families by The Ambulance Services Charity (TASC).

‘Most people will normally feel some levels of stress throughout their day—the fight or flight model enables us to cope with difficult situations,’ says Jean Hayes, director of support services for TASC. ‘However, prolonged levels of stress can sometimes have a negative impact on health and wellbeing. For some ambulance personnel, constant and increasing exposure to difficult situations may result in poor health.’

Hayes explains how since its launch in March 2015, TASC have been approached by a number of ambulance personnel suffering from low mood, stress-related illness and undiagnosed PTSD, many of whom remain in work providing a dedicated service to the general public.

As a result, the charity is currently developing a programme of support for individuals, working with a leading psychologist, which will enable ambulance personnel to recognise their own symptoms and develop strategies to help manage poor mental health.

‘Subject to funding, TASC aim to roll out this programme of work nationwide,’ says Hayes. ‘Along with other support services, TASC are here to support those working in the UK ambulance services, whenever they are facing unexpected difficulties, crisis or are in need.’

The College of Paramedics has been working closely with Mind over recent months, and is an active participant in the blue light mental health agenda nationally, along with the Association of Ambulance Chief Executives (AACE).

According to David Davis, paramedic and fellow of the College of Paramedics, the College has recognised the importance of the mental health and wellbeing of paramedics and other ambulance and pre-hospital professionals for a number of years. These include significant concerns around what many feel is an unachievable retirement age of 68, significant changes in working practices and increased workloads resulting in increased isolation of practitioners, as well as concerns over violence and aggression towards emergency services workers.

‘The research undertaken by Mind, as part of the Blue Light Programme, has reinforced anecdote with real meaningful data about the level of problems, and importantly revealed that many frontline staff were not keen on being open about mental ill health and stress for fear of either embarrassment or adverse consequences from employers or otherwise,’ says Davis.

‘The most recent data was very worrying indeed,’ he adds. ‘Particularly that 35% of those ambulance staff completing the online survey had contemplated taking their own lives.

‘There is increasing awareness of the risk of suicide among paramedics and other emergency ambulance service personnel that simply cannot be ignored, and the recent data from the Mind survey tells us that actions must be taken now to support and protect this important group of public servants.’

Davis, who is spokesperson on mental health for the College of Paramedics, goes on to highlight that the recent College of Paramedics conference revealed a clearly expressed mandate to make mental health of the membership a priority and to support the Mind programme.

‘A single suicide of one of the brave men or women who I am proud to call my colleagues is a tragedy too many,’ says Davis. ‘We must work together to tackle the issues of mental ill health, whether they be stress, depression, anxiety or post-traumatic stress disorder.’

The AACE is one of the national associations signed up to the Mind Blue Light Time to Change pledge and were fully engaged in the Blue Light Programme throughout its initial duration. According to Anna Parry, national programme manager for the AACE, the association is continuing to benefit from the work undertaken by Mind, with the Time to Change Programme Manager contributing to ongoing work the AACE is overseeing to promote and enhance the mental health and wellbeing of staff. At the national level, the AACE is collating information and data in this area to better understand what more can be done to support ambulance service staff.

‘The sector feels that there is more that could and should be done to fight mental health stigma and discrimination and to enhance the supports that are available to staff in this area,’ says Parry.

‘The mental health and wellbeing of staff subsequently features in the AACEs 2016–17 strategic priorities; these are identified and progressed by ambulance services nationally,’ she adds.

Removing the stigma

Project M (4)Farnworth believes that with ever increasing demand on the ambulance service, there is not as much opportunity for discussion and reflection between jobs anymore.

‘When staff attend a particularly traumatic job, they are offered some “time out” but many staff don’t take this up when they know there are patients out there waiting for our help,’ he says.

‘As much as we look out for each other, there is still a bravado or “stigma” attached with this job; we all like to think we are infallible. We are there to support the public in [their] time of need, but we tend to not ask for help ourselves.’

‘Talking to my peers has also been a massive help,’ says Farnworth. ‘It helps me realise that what I’m going through is normal, and that many people experience things like this from time to time.’

This sentiment is something that Myers finds he can also relate to:

‘The first piece of advice I would give would be “do not be ashamed”. It took me a long time to admit both to myself and to those around me that there was something wrong. There is still a stigma attached to mental health issues, particularly PTSD, in a field where it is expected that you just get on with the job, that prevents people from seeking help. A first-line defence must be to talk, be it to a colleague, a friend or a relative, or, if the need arises, to a medical professional who will be able to give guidance with reference to the right course of treatment if required.

‘Don’t be afraid to seek help. Because the subject up until very recently was taboo, it was not well known how and where to seek help, but I believe that it’s slowly improving.’

Rifai also believes that stigma surrounding mental health should be removed: ‘There is no shame or stigma attached to experiencing mental health problems, it’s just the same as breaking a bone, except no one can see that you are suffering. We are not super humans and we are just as prone to illness as anyone else, if not more.’

Blue Light Walk

To help raise awareness of mental health problems within the blue light community and get emergency service personnel talking, Farnworth has teamed up with Richard Morton, paramedic; Philip Baggaley, senior paramedic; and Gill Despard, paramedic lecturer practitioner, to walk from Scarborough RNLI to Blackpool RNLI stopping at fire, police and ambulance stations along the way. They will be raising money for the Blue Light Programme.

The walk will take place from 26–30 September and they are inviting all emergency services, as well as the general public, to join them on the ‘last leg’ from Broughton ambulance station to Blackpool RNLI. Additionally, they are putting on a Blue Light Walk Charity Ball to celebrate the success of the walk on 1 October. If you would like to support their cause or join them then visit http://www.bluelightwalk.com.

Has your mental health been affected as a result of working for the ambulance service? If so, Journal of Paramedic Practice would like to hear from you. Email jpp@markallengroup.com

Taken from Journal of Paramedic Practice, published 6 May 2016.

The bare necessities: delivering first aid in the Calais ‘Jungle’

Student paramedic, Sam Wheeler, treats treats a Sudanese refugee who burned his hand after the tarpaulin used to make up his tent caught fire. Photo Credit: Rose Oloumi

Student paramedic, Sam Wheeler, treats a Sudanese refugee who burned his hand after the tarpaulin used to make up his tent caught fire. Photo Credit: Rose Oloumi

It’s 11:00 am and a group of 20 people are congregated in a small area between three caravans lined up to form a triangle. Amid the din of Arabic, Farsi and French, snatches of broken English can be heard complaining of sore throats or noses that are ‘closed’. A number of medical volunteers are busily trying to organise a queue, with shouts of ‘one at time’ having to be regularly made. This pandemonium could be any health professional’s idea of a nightmare, but this is just another day in the Calais ‘Jungle’.

These volunteers, made up of doctors, nurses, paramedics and students, have sacrificed their weekend to provide first aid within the refugee and migrant camp located on the outskirts of the city. They form part of the Refugee Support First Aid and Care Team, who since September 2015 have been delivering care from the heart of the ‘Jungle’.

Introducing a first aid team to the Calais ‘Jungle’

One of the first aid caravans situated in the camp. Photo Credit: Rose Oloumi

After hearing about the lack of basic medical care available to refugees and migrants in the ‘Jungle’ over weekends, Liz Gall, a luxury wedding planner and former retail bank manager, set up Refugee Support. Founded on 9 August 2015, the aim of the organisation is to take aid over to refugees and migrants residing in the Calais ‘Jungle’.

‘After living in the jungle at weekends for a month, it became apparent that there were no medical facilities available either at night or on a weekend,’ says Gall.

Current medical aid delivered in the camp is limited. As a result of the ‘Jungle’ not being recognised by French authorities as an official ‘refugee camp’, no large charities or humanitarian groups have a real presence on the ground.

Médecins du Monde (MdM) (Doctors of the World) has provided essential medical help to refugees and migrants living in and around Calais and Dunkirk since 2003, but withdrew from the ‘Jungle’ at the end of 2015 after a theft from their building. Médecins sans Frontières (MsF) (Doctors without Borders) has provided aid since early December and runs a health clinic that is open Monday to Friday. However, it is believed its contract ended on 1 March.

It was because of this that Gall felt the need to set up Refugee Support:

‘Following a conversation with Hassan Chaudry (GP) and Raid Ali (dentist) on return from Calais on 14 September, we decided that as there were UK healthcare professionals wanting to help, we would try and make it happen.

‘Our original aim was to provide care on weekends, when MdM were not in the camp. Refugee Support First Aid and Care Team and Refugee Support Dental Team were borne out of this.’

With help from Caravans for Calais, Gall arranged for a caravan to be sent to the ‘Jungle’ from the UK, with the aim of using it as a mobile clinic for refugees and migrants.

‘On Saturday 26 September we opened our first caravan and treated people on the street in the jungle,’ recalls Gall.

The caravan was funded by a group on Facebook called the Creative Collective for Refugee Relief, who had raised money by selling their artwork online. Two further caravans were sent over in the following 2 months to be used for first aid, as well as an additional caravan for dental care.

Map of Calais ‘Jungle’ highlighting medical care points. Map Data ©2016 Google

Map of Calais ‘Jungle’ highlighting medical care points. Map Data ©2016 Google

Volunteering in the ‘Jungle’

First aid shifts within the camp are coordinated through the Refugee Support First Aid and Care Team Facebook group. Health professionals input their dates of availability, as well as contact information and important details such as their registration number. Registration is then checked against the appropriate regulatory body and dates confirmed. Paramedics currently make up a relatively small percentage of the overall first aid volunteers, with the majority being made up of either doctors, nurses or medical students. So far, over 400 people have volunteered as part of the Refugee Support First Aid and Care Team at the camps located in Calais and Dunkirk.

Dan Evans is a final year medical student at Cardiff University overseeing the first aid caravans as team leader over March. He has been at the camp for 2.5 weeks as part of his medical elective and has another 2 weeks remaining.

‘The vast majority of work is making sure people aren’t unwell, aren’t septic,’ says Evans.

According to Evans, patients are predominantly treated for minor ailments such as colds, flu, sore throats and the nasty variety of chest infections referred to as ‘Jungle lung’. Additionally, broken bones, bruises, sprains and cuts are treated following altercations within the camp or with police, or failed attempts at crossing the border into the UK.

The three caravans used by the first aid team are situated towards the north end of the camp and offer patients a private space for consultations. Where possible, patients are treated there and then. In cases where additional care is needed or follow-up required, patients are referred to the clinic run by MsF. Outside, strepsils, cough medicine and bracelets made from tubigrip and cotton wool soaked in olbas oil are dispensed from a counter made of chipboard.

While the majority who come to visit the caravans receive some medicine and are sent on their way, a small number who turn up are considerably unwell. Notably on this weekend, a young man is seen crouched on the dusty floor, cradling his head in his hands. After an examination by a doctor in one of the caravans, it is recognised he has meningitis and is subsequently rushed to the emergency department in the city.

Among the first aid volunteers at the ‘Jungle’ on the weekend of 12 March are a group of student paramedics from the University of Surrey, who between them raised over £1,000 to go towards medical supplies for the caravans.

They used part of the donations to purchase two paramedic rescue backpacks to enable them to act as a mobile clinic and provide first aid on foot to those in need.

Shadowing the students, it is apparent that being able to bring care to those who may not be aware of the existence of the caravans, or who might fear the implications on their claims for asylum by visiting a clinic and having their details recorded, offers the volunteers access to patients not possible before.

‘We have done something really good with starting an outreach programme which they didn’t have,’ says Javier Garcia-Marcos, a second-year student paramedic. ‘As student paramedics I think we are best placed to do that.’

On this weekend alone, a Sudanese refugee is treated for a burn after the tarpaulin used to make his tent caught fire; an Eritrean refugee who was stabbed in the back following an argument in the camp has his dressing changed; and a Kurdish woman who was afraid to visit the MsF clinic is revealed to be pregnant. Having been trying for a child for 5 years, she thanked the student midwife with tears in her eyes and proceeded to invite her inside her caravan for tea.

The general mood within the camp appears friendly, with many of the refugees and migrants all too happy to offer their seat or extend invitations for a hot drink. Yet despite this, there have been a number of reports of volunteers being attacked or intimidated.

When asked whether he feels safe, Evans pauses for thought:

‘There is a lot of crime as everything is unregulated, but I wouldn’t describe it as dangerous,’ he says. ‘If you are British and not wearing a police uniform, people know you are here to help,’ he adds.

The lack of police within the camp is evident and it is clear their presence is not welcome. Instead they stand in groups around the perimeter of the camp, clad from head to toe in riot gear and ready to intervene should any situation escalate.

Speaking to some of the other volunteers, they agree the overall feeling within the camp appears to be positive:

‘The general mood was quite good. I didn’t find any aggressive people and they were quite accommodating,’ says Omar Yusof, a second-year student paramedic at the University of Surrey.

‘I think people need to remember they are not just refugees, they are people,’ says Jordan Wheeler, a second-year student midwife at the University of Surrey. ‘They are just like us, it is naive to refer to them as locals.’

While the volunteers describe the experience as memorable, it has evidently not been without its difficulties:

‘You feel a bit useless as there is no referral,’ says Wheeler.

‘It is difficult to assess people properly due to very basic equipment, it is also difficult to communicate,’ adds Sam Wheeler, a second-year student paramedic at the University of Surrey. ‘However, it has given me a big boost in confidence. Working in a different environment you have to be inventive.’

When asked what advice the volunteers would give to those considering coming out to Calais, they give out a series of practical steps:

‘Bring your own diagnostics kit,’ says Yusof. ‘It would also be best to have people well trained in minor injuries.’

‘Come in teams as that is the way we are used to working. I think working in twos and threes works really well,’ says Garcia-Marcos. ‘Also, try to learn a few words in Arabic, it opens a lot of doors.’

Student paramedic, Javier Garcia-Marcos, examines an Eritrean refugee complaining of knee pain. Photo Credit: Rose Oloumi

Student paramedic, Javier Garcia-Marcos, examines an Eritrean refugee complaining of knee pain. Photo Credit: Rose Oloumi

Future plans

Refugee Support is currently in the process of registering as an official charity, and according to Gall, the future looks bright:

‘In 6 months what we have achieved is phenomenal. Our original aim was to provide weekend care, yet since December we have covered 7 days a week.’

However, the recent destruction of the southern section of the camp—which left up to 3 500 people without homes—and the proposed demolition of the northern section, has meant things have had to be taken one day at a time:

‘As the requirements within the camp change we must adapt with them,’ says Gall. ‘We were due to have a wooden first aid centre built in Calais, but this is currently on hold until we can be certain that the latest news to maintain the northern part of the camp is happening.’

As a result of regular evictions and demolitions, life in the ‘Jungle’ is constantly forced to change. On 4 March, a re-purposed double decker bus was delivered to the camp to replace the Women and Children’s Centre that disappeared when the southern part of the camp was destroyed. The aim of the bus is to offer a safe living space on the ground floor for women and children, and a dormitory upstairs intended for unaccompanied minors. Additionally, a vaccination clinic set up by Health and Nutrition Development Society (HANDS) International, who have been immunising against influenza and measles, was also forced to move.

However, this constant need for adaptation has not dampened the determination of the volunteers who come to Calais. There is no denying that in the short time since its inception, Refugee Support has gone from strength to strength, yet Gall emphasises it has only been possible because of the people who have dedicated their time to making it a growing concern.

‘We have the most amazing volunteers, and are so grateful to them. Because we are a small group and they are so compassionate, we can adapt at reasonably small notice,’ she concludes.

For more information, or to register your interest in volunteering, visit: www.facebook.com/groups/CRS.UKMEDTEAM/?fref=ts

Taken from Journal of Paramedic Practice, published 1 April 2016.