North Norfolk's Hollow Victory

North Norfolk are celebrating making East of England Ambulance Service “rethink” their new deployment strategy which proposed the removal of full-time ambulance cover from the towns of Cromer and North Walsham. According to the Eastern Daily Press “they are taking another look at the controversial shake-up of cover and they have already agreed to amend heavily-criticised proposals.”

The “efficiency” proposals announced earlier this year were met with public outcry which gained momentum as MP for North Norfolk Norman Lamb and some notable celebrities added their voices to the cause. Now the decision-makers at East of England Ambulance Service have apparently U-turned after rising demand “triggered a clause in their contract”, leading to an extra £3m in funding which has allowed the provision of 2 (almost) full-time ambulances at Cromer and North Walsham.

Sorry North Norfolk, but it's not nearly enough - at best, you've been given a sugar-coated excrement sandwich. For a start, if it has suddenly come to the attention of the decision-makers that demand was on the increase, how could they justify any kind of withdrawal of cover in the first place without checking the figures first? Why did it take a public outcry for anything more than fuzzy logic and assumption based on old figures to be applied?

What Kind of Ambulance Were You Expecting?

Inexplicable decision-making aside, before we take a look at the initial proposal and the subsequent impact of the “rethink”, we should get some context as there is a lot of reference to some fairly cryptic abbreviations (which will be used as little as possible here).

Emergency ambulance cover nationwide is provided by a number of “resources” and it is of critical importance to understand what kind of service each provides. Not every resource will necessarily mean the arrival of all the services needed at an emergency.

DSA – Double-Staffed Ambulance: For the most part, Double-Staffed Ambulances are what are expected when 999 is called: A fully-equipped ambulance capable of a wide range of treatment and the swift transportation of an incapacitated or critically-ill patient to hospital. The expectation is that the crew aboard will include a Paramedic – an individual qualified and experienced in the provision of advanced pre-hospital medical care. In most cases this will be true, but the choice to call them “double-staffed ambulance” is ambiguous enough to be able to fudge this. It is not unknown for a vehicle with all the required equipment to arrive on scene, but with the staff aboard unable to use it all.

RRV – Rapid Response Vehicle: This is a car (and very rarely a motorbike), driven in most cases by a Paramedic.  There has been a recent shift in policy to ensure all Rapid Response Vehicles would be Paramedic-crewed, providing capability to treat most emergencies on scene. However, they would be unable convey patients to hospital and would be limited in what physical assistance could be offered. A collapsed or unconscious patient would have to remain in position even if it meant leaving an elderly woman with a suspected hip fracture on an icy path or a cardiac arrest sufferer on a bed (where CPR is ineffective). Technically-speaking, a single responder would not be allowed to move the patient even if they were able, but they would likely try anyway if circumstances demanded it. The Rapid Response Vehicle clinician would need backup in the form of a Double-Staffed Ambulance or Intermediate Tier Vehicle (see below) for emergency transport.

ITV – Intermediate Tier Vehicle: These are transport ambulances most often crewed by Emergency Care Assistants, who are trained in basic clinical skills only. The vehicle they use would be capable of transporting patients to hospital, but the crew would be very limited in what care they can provide due to the limitations of their training. In many cases, the vehicle itself will have all the equipment to support a higher level of care, but the crew would not have the skills to use it. The thinking behind Intermediate Tier Vehicles is that they would be sent to non-emergency patients requiring transport or to provide additional resources and transport to a Paramedic on an Rapid Response Vehicle (who would travel with them if required). Essentially, Intermediate Tier Vehicles are a cost-saving product of the increase in ambulance demand as a result of the general public's growing reliance on the emergency services for non-emergencies.

CRU – Cycle Response Unit: This is an ambulance clinician on a push-bike, designed to act as a first response measure much the same as the motorised Rapid Response Vehicles, but with the advantage of being able to access heavily pedestrianised city centres. Norfolk has these in Norwich, King's Lynn and Great Yarmouth.  Obviously patient transport is out of the question and equipment is limited by what can be secured safely to a push-bike. The Cycle Response Unit clinician would require backup from a Double-Staffed Ambulance or an Intermediate Tier Vehicle.

As can be seen from these explanations, although the ambulance staff who arrive at the scene of an emergency will have every intention of providing the care needed, in many cases they are not equipped to do so to the fullest extent. Clearly, in a genuine life-threatening emergency, a Double-Staffed Ambulance is what would be required - even if acute conditions like severe asthma or diabetic coma can be resolved on scene, hospital assessment and treatment may still be required. Anything less is straight from the “it's better than nothing” school of thought.

Emergency Cover in Norfolk

In the context of the proposals for Norfolk (and Suffolk) as laid out in the table below, let us consider the logistics. Excluding Greater London and the Isles of Scilly, of the 83 counties in England, Norfolk is the 5th largest by area and the 25th most populous. Aside from the city of Norwich, Norfolk is a flat rural county dotted with small towns and many villages. As such, the road infrastructure is comparatively underdeveloped, with access to many population centres only possible via small, winding roads.  As many locals will tell you, nobody gets anywhere quickly in Norfolk.

Every run to and from an emergency is an arduous and lengthy slog if you combine these factors with the scant availability of Accident & Emergency departments; the centrally-located Norfolk & Norwich on the western outskirts of the Norwich suburbs, the Queen Elizabeth Hospital in King's Lynn in the far north-west corner of the county, and the James Paget Hospital on the southern tip of Great Yarmouth in the south-east. It's little wonder there is concern from the population of the vast areas that are significant distances from all three.

So with these factors in mind, take a look at the proposal table published in the Eastern Daily Press on 18th August 2012.

Table of Current & Proposed Ambulance Resources in East Anglia (click to enlarge)
At first glance that is a baffling array of fairly abstract numbers, but there is sense to be made. To summarise, with 168 hours being 24/7 cover, these figures suggest roughly 5 less Double-Staffed Ambulances. In their place will be 0.8 Rapid Response Vehicles, 2½ Intermediate Tier Vehicles and almost a whole person on a bike. Even with the partial back-pedal (sorry, couldn't resist) on the cover in Cromer and North Walsham, they've only given back 1½ Double-Staffed Ambulances, meaning still over 3 ambulances less. Possibly more.

Oddly, going by the figures on this table, despite the Double-Staffed Ambulance hours being reduced by a total 811.5 hours - which equates to 4.8 full-time ambulances – the total DSA vehicles shown is reduced from the current total of 38 to 31 under the proposal, suggesting a reduction of 7 ambulances. I cannot explain this disparity.

The Grim Reality

Ambulances queues: a common sight outside A&E departments
Even before any of the proposed changes, the scattered ambulance resources in operation today are woefully inadequate. The precious few Double-Staffed Ambulances will routinely find themselves driving twenty miles or more to attend an emergency call - a journey that will easily exceed half-an-hour even with perfect driving conditions and copious use of the lights and sirens. Transporting a patient to the nearest A&E will likely take just as long and then the ambulance will continue to be unavailable for another emergency for as long as it takes to transfer the patient over at hospital (this in itself is a huge bottleneck as there are likely to be many ambulances attempting to do the same). When the ambulance crew is able to take another call, it will most likely be the moment they become available at hospital (or at the location of their previous attendance if transport was not required). Irrespective of the locality to which they are assigned, they will rarely be nearby and almost never in the town considered to be their base.

A lone RRV at a 3-vehicle collision
As the Double-Staffed Ambulances are quickly accounted for by these demands, all that is left is for the lesser resources to be assigned. In this way, the Rapid Response Vehicles and Intermediate Tier Vehicles find themselves responding to calls suited for Double-Staffed Ambulances and become stranded with a potentially critical patient unable to do anything more than attempt to stabilise them or hold their hand and give them some oxygen. All things considered, this is surely evidence that more Double-Staffed Ambulances are required, not less!

Given that these kinds of “efficiency measures” (read: cutbacks) are quietly being proposed around the country, the North Norfolk revolt has led the way in terms of expressing public dissatisfaction at these negligent proposals. But anyone who thinks that taking away over 3 ambulances and replacing them with first responders and under-trained staff is a victory, should perhaps consider a “rethink” of their own.

According to the Eastern Daily Press' jubilant article on the provision of these “extra” ambulances, Denise Burke, chairman of North Norfolk Labour Party said “We are pleased that the ambulance trust is listening and that north Norfolk will gain extra health emergency vehicles.” This gives the impression that those "extra" emergency vehicles will be providing cover for Cromer or North Walsham instead of the reality which is that they will be dragged far south in a doomed attempt to make up for the cuts – sorry, efficiency measures  –  elsewhere.

There is a long way to go before anyone can rest comfortably in the knowledge that there is an ambulance nearby.

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