So far on this blog, I think we've established that the "ambulance problem" is huge. Every opinion I have heard - from the public to paramedics to chief executives - has underlined the many intolerable issues that beset patients, crews and the service as a whole. The problems are so vast and manifold, it seems as if those in charge are incapable of addressing them, choosing instead to skirt around the problem, chipping away at minor contributing issues instead of tackling the core cause head-on.
Part of the problem is the vast differences between how various key parties perceive the ambulance service. In an effort to address the "ambulance problem" constructively, far more needs to be done by these parties to agree on what the ambulance service is for and then to execute that single purpose with efficiency and professionalism.
The Public Perception
Ultimately, the ambulance service is there to serve the public. But does this mean that the public knows best? Not at all. Few members of public give any thought to the ambulance service until they find themselves in a situation they cannot deal with, without outside help. The convenience of the 999 service means that for many, it is a catch-all solution. From their perspective, dialling 999 is the instant answer to a broad range of unmanageable problems. In some respects, this is good thing. It means that the UK public have faith in the emergency services provided. But the public demand on ambulance services lies at the core of the problem and the current inability to meet it is already eroding that faith.
So why do the public have this perception of the ambulance service's ability to deal with all health problems rather than just emergencies? I would argue that it has been brought about by a number of factors, but a large contributor is because that is how the ambulance service has sold itself to the public in the recent past. It is a legacy of the Bradley Report "Taking Healthcare to the Patient
" which, in 2005, set out a national template to provide "effective mobile healthcare". In the face of rising demand, Peter Bradley set the UK's ambulance services on a path to adopt a more holistic approach to the services provided.
On reflection, this seems naïvely optimistic with a touch of hubris. Essentially, the report declared that UK ambulance services were capable of taking on more work despite identifying a yearly rising demand of 6-7%. This apparently created a belief amongst the government decision-makers that the lofty healthcare goals set out by the Bradley Report could be achieved with existing resources, simply by reorganising ambulance services which, at the time, were described as working "harder rather than smarter".
Repeating the Same Mistakes
Now, seven years later, this same naïve philosophy is being touted as the solution to the current crisis. Despite a continued year-on-year increase of demand, a "fiddling whilst Rome burns" approach to re-arrangement and tweaking of resources will once again kick the can down the road whilst the results are analysed and debated in committee over the following months or years. Meanwhile, demand will continue to rise, patients will more frequently be made to wait and suffer, road staff will continue to be stretched thinner and thinner. Clearly, lessons have not been learned.
So the public perception of an increasingly unreliable service will grow. There is already no shortage of media coverage showing how seriously wrong things are. This brings us back to the core problem. The painfully mismatched juxtaposition of increasing demand and falling resources will not be resolved by half-measures like better call-handling and refining the application of existing resources. Making the service provided more efficient is of course a necessity and would be expected of any organisation, but it is glaringly obvious that current resources are not nearly enough to cope today. They are minor changes which cannot possibly make a dent.
The reason for this is because there is a on ongoing failure to address the core problem.
Vast sections of general public do not have the education, understanding or desire to work with the ambulance service to make things better. In today's consumer led environment, the ambulance service labours to provide the service that is expected of it by modern society, whilst most consumers simply expect the service they feel they deserve to be provided. In decades past, people would be grateful for a stranger to provide help. Now they pay their taxes and expect the NHS to provide everything - end of discussion.
Modern, materialistic, over-entitled, convenience culture is key to the rise in ambulance demand. 100% of the general public in the UK rightly expect a world-class ambulance service (and on occasion, they get it). But does that same 100% of the public also know what to do before an ambulance gets to them? Not even close. Sadly, the outcome of many emergencies are decided before a healthcare professional ever arrives. Even worse, so many ambulance resources are used dealing with problems that are not appropriate. Vast amounts of money are being spent attempting to deal with this misappropriation of resources, but not nearly as much in educating the public.
There are of course many individuals who do make informed decisions and use existing services responsibly, but they are a minority. The ambulance service is being slowly crushed under the weight of a self-serving public attitude - they expect the help, but will not help themselves.
Shockingly, the problem does not end with the general public. Elements of NHS culture itself cause a further strain on emergency resources. Whilst the ambulance service - a comparatively modern concept - works on the logical basis that people become ill twenty-four hours a day, seven days a week, other aspects of UK healthcare cling to the concept that reducing cover outside of core office hours is acceptable. After all, people rarely have problems at weekends or during the night, right? GP services are particularly guilty of this - begrudgingly putting on a skeleton service in "anti-social" hours - which, due to public perception, essentially shifts their workload onto emergency ambulances. Anecdotally, I found the number of 999 calls from GP surgeries close to the end of their working day suspicious too.
This same culture also causes similar workload bottlenecks within hospitals and even in the ambulance service itself - exhausted crews at the end of an intolerable shift might take a patient to hospital unnecessarily - or leave a patient at home inappropriately, in a desperate bid for some respite.
The Result of Cultural Abuse
The end result of this cultural abuse is that a service that is only funded to provide emergency care is unavoidably attempting to provide a much broader service. If the funds are not available to provide Peter Bradley's "effective mobile healthcare", then the public should be clearly informed as such.
As was pointed out in a recent message I received from a reader; "there are two ways to go about funding anything, the right way is to decide on a level of service and foot the resulting bill. The wrong way is to set a budget and keep to it and suffer any consequences which may arise from failing to meet operational targets." The latter is the current approach.
Today's ambulance services should not be forced by NHS culture and government targets to pretend they can provide services that are far beyond their capability. Equally, they cannot be held accountable for the shortcomings of a society filled with individuals not prepared to take responsibility for themselves and each other.
Ambulance boards need to stop fiddling whilst Rome burns and must take a more hard-line approach to saving the organisations they are pretending are still functioning well. They have to stop being held hostage by government budgets and targets and - more importantly - they need to stop deceiving the public and deluding themselves.
The public themselves need to step up if they wish to continue enjoying the privileges of healthcare deserving of a progressive first-world nation. The majority of adults have taken the time to learn to drive, but far fewer have been prepared to devote a similar amount of effort to learn basic first aid or even taken the time to understand their own medication. In modern life, people do not have the time or motivation for something they perceive to be trivial or inapplicable to them.
It is fair to say convincing the entire adult population of the UK to take more responsibility to learn basic skills is a gargantuan task. But children in schools are a different story. The simple inclusion of a few days first aid training and education about how the NHS works as part of the National Curriculum
(perhaps in Biology or Physical Education?) would soon produce an entire generation of informed people creating a future where first aid is commonplace. Knowledge would spread, common sense would prevail and public perception of the ambulance service and the NHS would be more accurate and more affordable. The general public would be in a far better position to make informed decisions and the resultant cultural knowledge shift would have a positive impact on the society’s demands throughout the NHS.
Everyone gets ill, everyone dies. Informed or not every individual in the land will, sooner or later, find themselves in a critical situation, yet the modern consumer will continue to expect somebody else to know what to do.
Hence the public’s present solution: Just dial 999 and hope.