Journal of Paramedic Practice

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.

Filed under Comment Tagged with A&E Delivery Boards, AIRWAYS-2, Ambulance handover delays, Ambulance Response Programme, Assaults on Emergency Workers (Offences) Bill 2017–19, Asthma Audit Development Project, CHM, College of Paramedics, Commission on Human Medicines, HCPC, Health and Care Professions Council, i-gel, Journal of Paramedic Practice, JPP, National Institute for Health and Care Excellence, NHS England, NHS Improvement, NICE, Nursing associate, Paramedic Evidence Based Education Project, Paramedic intubation, Paramedic prescribing, Prescribing, Quality Standard on Trauma, Supraglottic airway device, Tracheal intubation, UK Ambulance Services Clinical Practice Guidelines

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

April 13, 2018 Leave a comment

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).

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.

Filed under Features Tagged with A&E, Ambulance Response Programme, Ambulance services, Bed blocking, Cold Weather Plan, Flu, Hear and treat, Hospital admissions, House of Commons Health Committee, Influenza, Journal of Paramedic Practice, JPP, Monitor, National Audit Office, National Institute for Health and Care Excellence, NHS, NHS England, NICE, Norovirus, Public Health England, Red Cross, Royal College of Emergency Medicine, Royal College of General Practitioner, Seasonal pressure, See and treat, Self-care, Social care, Urgent and Emergency Care Review, Winter

What’s next for England’s ambulance services?

November 23, 2017 Leave a comment

Adobe Spark (7) Details of the delivery of new ambulance standards were outlined by the National Clinical Director for Urgent Care at the Health and Care Innovation Expo in Manchester (NHS England, 2017a). Professor Jonathan Benger provided delegates with an overview of the Ambulance Response Programme, which he called: ‘the way we should do change in the NHS—change that is evidence based from the very beginning.’

Outlining the programme

The implementation of the Ambulance Response Programme was announced by NHS England (2017b) in July, following recommendations by the NHS England National Medical Director, Professor Sir Bruce Keogh, to the Health Secretary (Keogh, 2017). It consists of three initiatives that were developed to try and improve clinical responses for patients.

Phase 1 involved changes to the triage of calls to allow more time for call handlers in cases that are not deemed as immediately life-threatening. This has been referred to as dispatch on disposition. Traditionally, handlers had up to 60 seconds to assess calls and establish the urgency of the problem, and the type of response required. It is at this point that the clock is started for the performance measurement. The subsequent issue was that in an effort to meet an 8-minute response standard, ambulance services were sending multiple vehicles to the same patient and standing down the vehicles they thought wouldn’t get there first. Response cars would frequently be used as a way of ‘stopping the clock’ but then the patient would have a long wait for the transporting ambulance, which was detrimental to the patient but not measured on the system. According to Benger:

‘The problem created was one whereby a paramedic in a response car might spend their entire day just driving from one call to another but never actually reaching a patient.’

The Ambulance Response Programme therefore sought to provide a more clinically appropriate response by targeting the right resource to the right patient. For non-life-threatening calls, ambulance call handlers were given up to an additional 3 minutes to determine what was wrong with the patient and therefore decide an appropriate response.

Phase 2 involved the introduction of a new code set that has four key categories, rather than two, which better reflects the wide range of needs patients have when they dial 999. In the old system almost 50% of calls to ambulance services are classified as Red 1 or Red 2, requiring a response within 8 minutes. However, this does not accurately reflect the type and urgency of care needed by patients (Turner et al, 2017). Under the new system there will now be four revised call categories:

Category 1 is for life-threatening calls. These are for people needing treatment for life-threatening illnesses or injuries and will be responded to in an average of 7 minutes
Category 2 is for emergency calls. These are potentially serious conditions that may require rapid assessment, urgent on-scene intervention and/or urgent transport. These will be responded to in an average of 18 minutes
Category 3 is for urgent calls. These are non-life-threatening problems involving patients needing treatment to relieve suffering. Often they can be managed at the scene and 90% of these patients will be responded to within 120 minutes
Category 4 is for less urgent calls. These are for non-urgent problems requiring assessment either face-to-face or by telephone and 90% of these patients will be responded to within 180 minutes.

The final initiative involved a review of the current ambulance system, Ambulance Quality Indicators (AQI), and the development of a revised set of indicators linked to the revised call categories.

Evaluating the programme

A formal trial of Phase 1 began in October 2015 and a trial of the Phase 2 revised call categories began in three services in April 2016. An evaluation of Phases 1 and 2 was published by researchers at Sheffield University (Turner et al, 2017). Benger said:

‘We are very fortunate in the Ambulance Response Programme to have very good stakeholder engagement and excellent independent academic scrutiny from Sheffield University.

‘They have analysed the data we’ve collected from more than 14 million 999 calls. Of those 14 million patients, no patient came to harm as a result of the Ambulance Response Programme.’

The review revealed that under the new dispatch on disposition system, early recognition of life-threatening conditions, such as cardiac arrest, will increase. The knock-on effect is up to an additional 250 lives saved each year. By sending an appropriate response, more vehicles will be freed up to attend emergencies, and patients will be conveyed to the appropriate place.

According to Benger, when call handlers were given more time, rather than impeding or reducing the speed of response for the sickest patients, speed and performance actually improved.

‘The ambulance services became a lot more efficient,’ said Benger. ‘Taking the entirety of both dispatch on disposition and the new coding set together, we were releasing 15 000–16 000 additional resources each week that could respond to a 999 call, when that was not previously the case. And that’s principally from putting an end to duplicate responses.’

Evaluation of Phase 2 on its own, however, is more complicated. The use of time-based standards as a key performance measure have been used by ambulance services throughout the world, despite a lack of evidence that they actually lead to good clinical care. As Phase 2 has only been operational for a short period of time, it is not possible to say whether the new model is better, only that it is ‘different’ (Turner et al, 2017). However, the three services reviewed indicated a period of operational stability during a period of high demand, even when response time performance continued to deteriorate in services operating the current national model.

It is thought that the more flexible approach to call assessment, resource dispatch, and response intervals brought on by the combination of dispatch on disposition and the
new code set, may reduce further deterioration in performance and maintain a consistent service. However, as highlighted by the researchers at Sheffield University, a system of ongoing review and refinement is needed to optimise delivery (Turner et al, 2017).

Implementing the programme

All ambulance services are now using dispatch on disposition, and the new call categories are intended to be fully implemented by winter 2017. This will hopefully reduce pressures on A&Es during their busiest time period.

‘We wanted to make ambulance services as efficient as they could be but that we didn’t lose sight of some of the core aims: prioritising the sickest patients, making sure we incentivise clinically and operationally efficient behaviours, and trying to reduce the long waits for patients,’ said Benger.

‘When I first started in my job, I noticed that when you gathered ambulance chief executives together in a room, they would spend about 90% of the time talking about ambulance response times and 10% about clinical outcomes. I’d like to reverse that.’

As demand for urgent and emergency care sees year-on-year increases, services have to adapt to reduce pressure and ensure patients are able to get the care they need. It is hoped the new ambulance standards will go some way to making this a reality.

References

Keogh B. Ambulance Response Programme—letter to Secretary of State [Internet]. Leeds: NHS England; 2017. Available from http://tinyurl.com/ybfgxmfx

NHS England. What next for England’s ambulance services? Leeds: NHS England; 2017a. Available from http://tinyurl.com/yb7vzk8g

NHS England. New ambulance standards announced. Leeds: NHS England; 2017b. Available from http://tinyurl.com/yc6ywmqs

Turner J, Jacques R, Crum A, Coster J, Stone T, Nicholl J. Ambulance Response Programme: Evaluation of Phase 1 and Phase 2. Final Report. Sheffield: School of Health and Related Research, University of Sheffield; 2017.

Taken from Journal of Paramedic Practice, published October 2017.

Filed under News Tagged with Ambulance Quality Indicators, Ambulance Response Programme, Bruce Keogh, Dispatch on Disposition, Health and Care Innovation Expo, Jonathan Benger, Journal of Paramedic Practice, JPP, School of Health and Related Research, University of Sheffield

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.

Filed under Comment Tagged with A&E, Accident and Emergency, Advanced paramedic, Advanced paramedic practitioner, CHM, College of Paramedics, Competency, Emergency medicine, Healthcare, Journal of Paramedic Practice, JPP, MHRA, National Institute for Health and Care Excellence, NICE, Paramedic, Urgent and Emergency Care

Passing the mantle: a parting farewell

August 11, 2016 Leave a comment

Adobe Spark This issue of the Journal of Paramedic Practice will be my last as editor. It has been an honour and privilege to edit a publication aimed at one of the most exciting healthcare professions, and I am grateful for being given this fantastic opportunity. I took over the journal in 2013, having previously worked on a nursing title, and in those few short years have witnessed a notable change within the paramedic profession.

The publication of the Francis report marked the beginning of my time as editor, and although not directly concerned with paramedics, it highlighted a need for cultural change within the NHS, with an emphasis on patient-focused care. This was followed by the long overdue update to the UK Ambulance Services Clinical Practice Guidelines, which was welcomed by the profession. The latest update was published earlier this year.

The publication of the end of study report for the Paramedic Evidence Based Project (PEEP), which called for the introduction of a national education and training framework for paramedics, marked a turning point for the profession and highlighted how its needs were changing. This was cemented in Sir Bruce Keogh’s Urgent and Emergency Care Review, which called for the development of 999 ambulance services so that they become mobile urgent treatment services. Illustrating an appreciation of the skill set of paramedics, their potential in the delivery of pre-hospital care was finally being recognised.

The Five Year Forward View expanded on these ideas and proposed a broadened role for ambulance services. It was becoming apparent that out-of-hospital care was becoming an increasingly important part of the work the NHS undertakes.

One of the most significant changes within the profession over the last few years has been the growth of its professional body. As of January 2016 there were 6 458 full members of the College of Paramedics. This represents 29.7% of all paramedic registrants of the Health and Care Professions Council, the regulatory body for the paramedic profession. The increase in members show the College is one step closer to its aim of becoming a Royal College, which requires that 50% of the profession are members of the professional body.

However, this evolution has not been without its difficulties. Reports of staff facing burnout, time taken off work due to stress-related illnesses, problems with staff retention, disputes over pay, and the fundamental problem of how ambulance services can cope with year-on-year increases in demand, mean the workforce is facing all manner of pressures.

Despite this, I believe these are exciting times for paramedics. As we gradually see a move to an all-graduate profession and changes to the paramedic scope of practice, the opportunities for work outside of the ambulance service are growing.

As I pass the mantle, I look forward to seeing the journal reach new heights following my departure under a new editor. It only remains for me to personally thank my consultant editors, the editorial board, and of course, you the readers, who have ensured the publication could continue.

Taken from Journal of Paramedic Practice, published 5 August 2016.

Filed under Editorial Tagged with College of Paramedics, Five Year Forward View, Francis Report, Journal of Paramedic Practice, Paramedic Evidence Based Project, PEEP, UK Ambulance Services Clinical Practice Guidelines, Urgent and Emergency Care Review

Pay survey reveals two thirds of paramedics considering leaving ambulance service

July 7, 2016 Leave a comment

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.

Background to pay dispute

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.

Profession suffering from high vacancy rates

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.’

Stress as contributing factor for those leaving service

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 .

Lack of opportunities for career progression

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.’

Profession facing possible industrial action over pay

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.’

Considering the future implications for paramedics

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.

Filed under Features, News Tagged with Agenda for Change, Burnout, College of Paramedics, Gerry Egan, GMB, Jeremy Hunt, Journal of Paramedic Practice, National Ambulance Strategic Partnership Forum, NHS Pay Review Body, Pay, Secretary of State for Health, Stress, Stress-related illnesses, UNISON, Unite, Vacany rates

Working together to improve efficiencies

July 7, 2016 Leave a comment

Adobe Spark (4) It was recently announced that the North East Ambulance Service NHS Foundation Trust, North West Ambulance Service NHS Trust and Yorkshire Ambulance Service NHS Trust will be coming together to form an alliance across the North of England (Association of Ambulance Chief Executives (AACE), 2016). The services have said the launch of the Northern Ambulance Alliance will help to improve the efficiency of ambulance services in the areas covered by all three Trusts.

It is important to stress that it is not a merger but an attempt by all three organisations to work closer together to improve patient care. Additionally, it is felt the alliance should help identify savings through collaborative procurement and offer improved resilience. So, in effect, the boards of each of the individual Trusts will still have responsibility for their individual service, but will also consider the work and objectives of the Northern Ambulance Alliance when making decisions.

One of the key driving forces behind the inception of the alliance was the Lord Carter Review (2015)into productivity in NHS hospitals, which supports identification of efficiencies and reduction of unwarranted variances. Some of the areas already identified where the Trusts can work together include looking at ‘efficiency through joint procurement exercises, major changes to IT, assessing specialist expertise and learning from each other’s achievements’ (AACE, 2016).

This alliance should be commended and highlights the overall commitment from each of the Trust’s to improve patient care. While demand for each service will inevitably differ due to considerations such as population and community, their strategic priorities are inextricably linked. It therefore makes sense that they should be considered together. More than anything, the alliance offers an excellent opportunity for the sharing of best practice and to tackle mutual difficulties. An example was highlighted by Rod Barnes, chief executive officer of Yorkshire Ambulance Service NHS Trust, of how the Trusts could come together to deliver on a single issue: ‘This might mean the procurement of a single agreed vehicle specification for all three services, identifying savings through the standardisation of maintenance and equipment contracts, which is something that has proved elusive at a national level’ (AACE, 2016).

It has been assured that there will be no direct staff consequences as a result of the alliance. However, it may mean in the future that the three organisations consider joint appointments or shared working for new roles and replacements.

It is hoped that other services will follow and create their own alliances. Who knows, it may even be one step closer to a single national ambulance service.

References

Association of Ambulance Chief Executives (2016) Three Northern Ambulance Trusts Form Alliance “That Will Improve Efficiencies”. http://aace.org.uk/ambulance-alliance-will-improve-efficiencies/ (accessed 27 June 2016)

Carter PR (2015) Operational productivity and performance in English NHS acute hospitals: Unwarranted variations. An independent report for the Department of Health by Lord Carter of Coles. The Stationery Office, London

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

Filed under Editorial Tagged with AACE, Association of Ambulance Chief Executives, Journal of Paramedic Practice, Lord Carter Review, North East Ambulance Service NHS Foundation Trust, North West Ambulance Service NHS Trust, Northern Ambulance Alliance, orkshire Ambulance Service NHS Trust, Rod Barnes

Ambulance service at creaking point

June 8, 2016 Leave a comment

Adobe Spark Recent figures published by NHS England reveal the ambulance service is continuing to fail to meet Government standards for responding to Category A (Red 1 and Red 2) calls. The figures for March 2016 showed only 66.5% of Red 1 calls were responded to within 8 minutes, while 72.3% of Red 2 calls received a response within the same timeframe (NHS England, 2016). This is compared to 73.4% and 69.6%, respectively for the same period in 2015. It marks 10 months that services in England as a whole have failed to meet the Government target of 75% for Red 1 Calls. The response to Red 2 calls is the lowest proportion recorded since the data collection began in June 2012. However, it must be highlighted that Red 2 data from February 2015 onwards are not completely comparable across England due to the introduction of Dispatch on Disposition, allowing up to two additional minutes for triage to identify the clinical situation and take appropriate action.

It has been a tough year for ambulance services, with London Ambulance Service NHS Trust being placed under special measures by the Care Quality Commission (CQC) in November 2015 and East Midlands Ambulance Service NHS Trust being recently rated inadequate by the CQC for safety due to insufficient staff numbers and a consensus that the skill mix of staff deployed was not always safe (CQC, 2016).

The fact of the matter is that demand for ambulance services continues to rise and services are struggling to keep up. The ambulance service in England received 861 853 phone calls in March 2016, compared to 694 188 in March 2015 (NHS England, 2015; 2016), a rise of 24%. However, Trusts have not been able to increase their numbers of staff to meet this demand. This creates greater work pressures and stress for existing employees, brought on by longer working hours and missed meal breaks. The result? High staff attrition within Trusts. Those that remain will no doubt be questioning whether this is sustainable. With staff currently being balloted by unions over industrial action on pay, the possibility of a crisis within the ambulance service cannot be dismissed as hearsay.

If this is to be avoided, a number of things have to change. Trusts must ensure front-line vacancies are filled and staff do not leave. This can only be done by fostering a work environment in which staff are happy to remain. The over triage of patients must be minimised so that appropriate resources are dispatched. And, where possible, patients’ needs must be addressed at the point of contact and unnecessary transfers to hospital must be avoided. If the ambulance service carries on as it is, it is difficult to see how it will continue to operate in 10 years’ time. By focusing on employee welfare, this crisis may be averted.

References

Care Quality Commission (2015) London Ambulance Service NHS Trust Quality Report, 27 November 2015. http://tinyurl.com/hxdhwpr (accessed 26 May 2016)

Care Quality Commission (2016) East Midlands Ambulance Service NHS Trust Quality Report, 10 May 2016. http://tinyurl.com/h5r4wfv (accessed 26 May 2016)

NHS England (2015) Ambulance Quality Indicators Data 2014–15. http://tinyurl.com/zf2p5jf (accessed 26 May 2016)

NHS England (2016) Ambulance Quality Indicators Data 2015–16. http://tinyurl.com/jyls6rt (accessed 26 May 2016)

Taken from Journal of Paramedic Practice, published 27 May 2016.

Filed under Editorial Tagged with Ballot, Care Quality Commission, CQC, GMB, Journal of Paramedic Practice, London Ambulance Service NHS Trust, NHS England, Response times, UNISON, Unite

Ambulance service contributed to loss of lives at Hillsborough disaster

May 13, 2016 Leave a comment

Adobe Spark (2) Following the longest inquest in British legal history, the jury of the Hillsborough disaster that occurred at the 1989 FA Cup semi-final between Liverpool and Nottingham Forest, ruled that lives were lost as a result of mistakes made by the ambulance service.

The disaster, which saw 96 Liverpool fans die and 766 injured, occurred after police opened an exit gate to alleviate the throng of people outside. This lead to a huge influx of supporters into two of the pens, causing severe crushing to those fans already in the terrace.

After hearing evidence for over 2 years, the jury of six women and three men reached a verdict of unlawful killing by a 7-2 majority.

They were asked 14 questions related to areas such as basic facts of the disaster, policing, behaviour of the supporters and defects in the Hillsborough stadium.

When questioned on the emergency response and the role of the South Yorkshire Metropolitan Ambulance Service (SYMAS) after the crush in the west terrace had begun to develop, it was agreed that error or omission on behalf of SYMAS contributed to the loss of lives in the disaster.

In particular, it was felt that SYMAS officers at the scene failed to ascertain the nature of the problem at Leppings Lane, and the failure to recognise and call a Major Incident led to delays in responses to the emergency.

Speaking after the ruling, Rod Barnes, Chief Executive of Yorkshire Ambulance Service NHS Trust, extended his sympathies to the bereaved families of those who lost their lives as a result of the tragedy.

‘We fully accept the jury’s conclusions that after the crush began to develop there were mistakes made by the ambulance service,’ said Barnes. ‘Lives could have been saved on the 15th April 1989 had the emergency response been different.’

He went on to apologise on behalf of Yorkshire Ambulance Service: ‘I am truly sorry. Our thoughts remain with the families as they continue to grieve and come to terms with the evidence they have heard over the last 2 years.’

‘As one of the successor organisations of South Yorkshire Metropolitan Ambulance Service, we have had a responsibility to ensure a full and fair examination of their response. We have done our best to make sure all relevant evidence about the ambulance service response has been put before the Court, placed in context and properly explored in an open way,’ he added.

He highlighted how the ambulance service has changed in the last 27 years and stressed how a lot has been learned from Hillsborough and other incidents.

‘We, as an organisation, are not complacent. I would like to reassure the public that the ambulance service’s ability to respond to a major disaster such as this has changed beyond all recognition.

‘We understand the importance of today for the families and friends of those who died. Our thoughts remain with them.’

In addition to the ambulance service, it was concluded that the South Yorkshire police were responsible for the development of the dangerous situation and subsequently contributed to the loss of lives due to a lack of coordination, communication, command and control, which in turn delayed or prevented appropriate responses.

The Prime Minister, David Cameron, said that the jury’s ruling of the Hillsborough inquests has provided ‘official confirmation’ that Liverpool fans were ‘utterly blameless in the disaster’.

Filed under News Tagged with FA Cup, Football, Hillsborough Disaster, Hillsborough Inquest, Journal of Paramedic Practice, Liverpool FC, Nottingham Forest FC, Rod Barnes, South Yorkshire Metropolitan Ambulance Service, Yorkshire Ambulance Service NHS Trust

Ambulance staff contemplate suicide due to poor mental health

May 11, 2016 Leave a comment

‘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

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

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.

Filed under Features Tagged with AACE, Anxiety Disorder, Aryeh Myers, Association of Ambulance Chief Executives, Bipolar Disorder, Blue Light Champion, Blue Light Programme, Blue Light Walk, College of Paramedics, Dan Farnworth, David Davis, Depression, Esmail Rifai, Journal of Paramedic Practice, Kevin Sibley, Mental health, Mind, Mind Blue Light Time to Change, Obsessive Compulsive Disorder, OCD, Paramedic, Post-traumatic stress disorder, PTSD, Schizophrenia, Stress, The Ambulance Services Charity

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