Tuesday, 9 October 2012

The Cult of ORCON



Yesterday, East of England Ambulance Service chief executive Hayden Newton announced his decision to take early retirement. On the same day, North East Ambulance Service tweeted that their chief executive, Tony Dell, has taken the same decision. There will likely be many theories as to their motivation to step down from their positions, but in the current climate, the chief executive role is undoubtedly a poisoned chalice. Their departures certainly won’t solve anything and whomever replaces them will be confronted with the same insurmountable challenges and cultural problems.

The Ambulance Service is about providing good pre-hospital healthcare where it is needed. It is the responsibility of the paramedics to provide the good healthcare. The “where it is needed” part is dealt with by the supporting organisation. Those two key components of effective ambulance care should work in tandem, but somewhere along the line they have become opposing forces. The primary task of remaining and future chief executives should be to put an end to this clash.

The Ambulance Commandments

The Ambulance Service exists primarily to deal with serious and life threatening emergencies, although their remit has become far broader in recent years.

In order to track performance and monitor the effectiveness of dealing with these incidents, a system was developed in 1974 called ORCON (Operational Research CONsultancy). This system set out key performance indicators, the primary one being that 75% of calls designated as immediately life threatening should receive an initial response within 8 minutes and 95% within 19 minutes.

The principle behind this target is to ensure that any potentially critical situation has appropriate resources on the scene as soon as possible in order to assess, stabilise, treat and transport as necessary. Any efficient and professional organisation certainly needs a way to measure how effective their service is and the ORCON standard was a reasonable basis for emergency ambulances.

Presumably, the difference between the 8 minute and 19 minute targets is to account for geographical challenges in more rural, low population areas where it would be enormously expensive to provide enough ambulance cover to reach calls in 8 minutes. This might also explain the thinking behind allowing a 25% expectation of failure in even the more accessible of areas. Essentially, it is a concession to the unaffordable expense of 100% cover.

So in essence, the targets which ambulances services UK-wide aim for already factor in broad scope for failure. It has been reasoned that situations will arise where attendance will be less than optimal due to location or lack of resources.

It is noteworthy that this standard only covers those calls designated as “Red One” and “Red Two” (formerly Category A). The distinction between the two is described on the Department of Health website here. The reworking of the “A8” (Category A - 8 minute) response times was part of a broader revision of ambulance response targets which took place this year. The 75% target has been changed, with the expectation of 80% success by April 2013.

The Category B target has been scrapped, instead being replaced by a number of “Green” targets.These require attendances from 19 to 60 minutes. In some cases the target criteria can be fulfilled with a phone call to clinically assess the situation.

The Logic Behind the Targets

In an ideal world, every genuine emergency would be attended immediately. Sadly, this is clearly impossible. However, the science behind the decision to choose 8 minutes as the highest standard is a mystery. There is no scientific basis in medicine that could underpin the logic. In the most dire of emergencies – a cardiac arrest – the heart has stopped and the brain is being deprived of the necessary continual supply of oxygen. Modern medical thinking suggests that tissue damage in the poorly oxygenated brain starts to occur within 4 minutes. This time can be lengthened with effective CPR, but sadly in so many cases, this does not take place. Presumably, the 8 minute target is based on the imminent expectation of cardiac arrest but some wiggle room has been applied. It is fair to assume that 8 minutes has more likely been selected because it can more reasonably be achieved from a logistical perspective. Sooner would be better, but “sooner” cannot be so easily measured. Eight minutes it is then.

The 75% (or soon to be 80%) is less justifiable. If we are to assume that every “Red One” is a cardiac arrest or a condition that may lead to a cardiac arrest, then why is it acceptable to disregard 1 in 4 (or 1 in 5) cases? Again, this can only be a logistical decision, certainly not ethical or medical. To claim that achievement of the 75% target is a complete success seems a little distasteful, but I’m sure that it is far more palatable in the board room than “25% failure”.

It is fortunate for the patient that paramedics do not hold themselves to such low standards. Imagine if the sufferer of heart attack, diabetic episode or asthma attack was told by the attending paramedic that he didn't need to administer any medication because he'd already met his 75% target for the month. Every paramedic is expected to get it 100% right, 100% of the time. Yet Ambulance Trusts have been instructed to aim for a much lower standard which they often fail to achieve.

One Target to Rule Them All

So far we have established that the principles of the “Red One” target are sound, even if the logic behind them is more than a little fuzzy. The underlying problem only becomes apparent when its application is examined.

Nearly four decades have passed since ORCON was introduced and the ambulance service has evolved considerably. Standards of practice have improved far beyond the “hump-and-dump” mentality of the seventies. The intervening years have seen the rise of the professional paramedic and a shift in focus to the myriad treatments, drugs and equipment available to provide a far more effective pre-hospital service.

In spite of this, ORCON targets remain the primary yardstick by which all ambulance services are measured. Admittedly, clinical and performance indicators have been recently introduced, which do monitor a variety of things from dispatch performance to heart attack diagnosis and successful treatment of cardiac arrests. But all of these targets remain a distant second to the “A8” commandment.

How the Ambulance Target Chasing Culture Became Toxic

Rather than treating ORCON standards as a guideline to encourage the provision of best possible service, in today's Ambulance Trusts the “A8” target has become fanatically enforced dogmatic law.

As an example, less than a year ago East of England Ambulance Service boasted that it had “smashed” the 75% target. It achieved 76.9% in September of 2011. Apparently 1.9% in one month constitutes a smashing and Chief Executive Hayden Newton was said to be “thrilled”. Not a mention was given to the 23.1% of calls that failed to be attended within time, nor was it clear what the final outcomes were of those 76.9% of attendances. It didn't matter, for one month, the Cult of ORCON had achieved ambulance perfection.

Therein lies the problem. Rather than the ORCON standard being seen as a means of giving the paramedics on the ground a fighting chance of saving lives by kick-starting a pathway of care that may eventually benefit the patient, it is seen as the be all and end all of ambulance service efficiency. The total victory scenario.

In truth, it is nowhere near that important. Worse than that, it has become a millstone weighing heavily on the real standards of the clinical practitioners out on the road. Ambulance staff are forced to deliver a sub-par service as they are pushed hard to meet the demands of this poisonous, target-led culture.

With Ambulance Trusts desperately trying to prove their government overlords that they are still capable of meeting these targets in the face of rising demand and reduced funds, they are increasingly resorting to dirty tricks, all of them eroding the true effectiveness of the service. Single-manned paramedic cars are used to reach the incidents within target time with no real hope of a transport option. The culture in dispatch centres desperately tries to find reasons to categorise possibly life-threatening calls they cannot get to as something of lesser priority. Road staff are driven into the ground by being hounded out of A&E departments and sent from county to county on an endless gauntlet of attendances for long hours at a time.

In a recent document, Hayden Newton stated, “...the Trust is reporting correctly in terms of a fully equipped ambulance response vehicle deemed to be a transportable resource.” He went on to cite an unattributed quote, possibly from a Department of Health document, “the A19 target specifically precludes motorbikes and pushbikes as clearly they cannot transport patients, however nationally we do see cars being designed to accommodate patients.” 

It may have been the intention of this statement to allow the use of cars with specially designed passenger/attendant compartments, but it has instead clearly been interpreted and implemented as “any car”. This has paved the way for lone paramedic Rapid Response Vehicles to be sent to inappropriate calls under the guise of a “transportable resource”, fulfilling target criteria, but failing to provide appropriate transport. Nevertheless, the Cult of ORCON is satisfied.

Throughout the infrastructure designed to support and empower clinicians, this kind of sinister manipulation of the system is taking place all too frequently. For the sake of a single target of apparently biblical importance, every other part of the ambulance system suffers.

Unnecessary Sacrifice

The end result is that – by hook or by crook – Ambulance Trusts will attempt to achieve this target and prove to the government that they have everything under control. There is no government target given as much importance, so all other considerations are secondary. That the welfare of patients and crews will be sacrificed to achieve them is irrelevant, the target must be met. Pursuit of this one hallowed goal is the fundamental basis underpinning every deployment change, rota redesign and cutback justification. As established earlier, the target isn't even that meaningful, at least not to those who really matter, but still the health of patients and staff continue to be offered up on the altar of ORCON.

Most worryingly, the senior management and the government seem unable to recognise that, in the face of budgetary restrictions, the fanatical enforcement of their “A8” religion is now doing more harm than good. Even with some of the high priests stepping down, the Cult of ORCON will remain strong unless challenged to once again make response time targets work alongside clinical standards, rather than to their detriment.

Trust Boards and chief executives should now seize the opportunity to make positive and informed changes to the cultural direction of Ambulance Trusts - with paramedic-led clinical care given equal value to the need for quick response times.

Or the sacrifices will continue...


44 comments:

  1. Brilliant brilliant brilliant !!
    Something I've been saying for years .
    I hope your application for chief is already winging its way to HQ.
    On FRV last night I got sent 15 miles to a 75yr old with chest pain, was informed he had had previous MI & was grey, clammy & collapsed. When I enquired if an ambulance was en route I was told " no there wasn't but that an early update from scene as to the level of backup would be appreciated "
    I wanted to scream at the dispatcher that I could tell him now what level I wanted !!!! not after I've driven 18 mins in the dark & pouring rain.
    Good grief give me strength.

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  2. Best article I have ever read regarding the problems within the ambulance service. Please send it to the health minister. For me this is a glimmer of light at the end of a very long and dark tunnel.

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    1. Retired north Norfolk parent of a paramedic9 October 2012 at 18:40

      I recieved confirmation yesterday that Norman Lamb has been appraised of this blog and I am sure his staff will bring this new post to his attention.

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  3. North Norfolk resident10 October 2012 at 11:55

    I have just read today’s EDP report on Nick Clegg’s visit to our part of the country and his backing of Norman Lamb and the EDP Ambulance Watch campaign. Couple that with the Labour party Act on Ambulances petition, it looks like Norfolk may have an “all party” YES to getting things sorted here in this county.

    Now that really does have me worried. Why? Because if Norfolk is taken as a special case, the problems that really matter may have been missed! If I understand everybody’s comments correctly, the problems maybe logistically magnified in Norfolk but they are nationwide. What’s happening elsewhere in the country?

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  4. Exactly, Norfolk are doing a grand job fighting their cause, whats the rest of EoEAS doing in there counties nothing, Mat is the only man who's working hard fighting for us, Unison are doing nought, GBM are doing more. There's been no mention in any local papers, the public in hertfordshire have no idea what's goinging on. Well Done Mat, your doing a grand job, keep up the great work.

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  5. Excellent article.
    Yes the response time target no longer means what it should because of manipulation, BUT when the targets were eased by doing away with national reporting standards for cat B and cat C calls it actually became ten times worse for patients for a number of reasons.

    Firstly it is very difficult to safely triage over the telephone and a call handler entering 999 details into an AMPDS data field is about the worst way of identifying cat A calls. I know AMPDS (which the NHS pays an american company licence fees for) has been modified for UK use but was never designed to not respond a resource in fact it only used to identify 50% of patients who were in cardiac arrest (It has improved a little since then).

    Secondly, although the idea of targeting resources at critical patients is a good one the accountants look on it as a way of saving money. There is an ideology within some sections of the government (is it 18 millionaires in the cabinet?) that public services such as the NHS are just a waste of money because we do not 'produce' anything or make profits for some billionaire shareholder or owner of an insurance or private healthcare company.

    It has never been identified that the ambulance service really is the 'cinderella' service and has struggled to cope with increasing call rates along a financial tightrope for many years. Where paramedics see a way of improving patient care accountants and ministers see 'efficiency savings' and 'unit hour utilisation'. They fail to see that ambulance resource levels went well beyond 'broke' many years ago and further 'efficiency' savings are futile. Perversely they also fail to see that it is a 'cut off your nose to spite your face' approach as it will also fail themselves and their family when they require an ambulance and qualified staff in a hurry (who else is going to respond to them be it Lord, Lady or someone they may call a 'pleb'). Yes they may subsequently get a private ward in hospital but thats if they survive the wait for the ambulance.

    Thirdly if you do not have the resources (double manned ambulances) to respond to the cat A calls and achieve your targets then you are going to reduce your standards for a cat A call by downgrading and manipulation.

    End result a 'third world' ambulance service with patients (particularly the elderly) waiting hours for ambulances, lots of cars but no ambulance to convey the patient.

    Someone needs to inform politicians, Trust board members and senior managers what the word 'ambulance' in 'ambulance service' actually means.

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  6. Re:Anon@21:39
    Maybe its an idea for people to contact their local press, make them aware of the issues and see if they are interested in setting up their own ambulance watch by pointing them in Mats direction. If a few people contact them separately it may perk their interest.

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  7. I totally agree with Anonymous@21:47 (great way of differentiating between all anonymous commenters by the way - but you can enter a nickname instead folks), it really is a matter of perception and sadly, those in the halls of power only see statistics, number and bottom lines, so unless there is a huge cultural shift, we will always see decisions dictated by the bottom line in preference to quality of service.

    As Anonymous@22:16 suggests, it would be great to see more local papers reporting these issues and starting campaigns. If local newspapers see themselves as responsible to their communities, they can provide a fantastic unifying service as the EDP Ambulance Watch and Act on Ambulances has shown in North Norfolk.

    I know the plight of East Midlands Ambulance Service is about to get the full force of the media spotlight, so others are coming forward too. I would be happy to work with any local newspapers in the EEAST region. Ultimately it is the voting public who need to stand up to these cutbacks by sending a clear message to government representatives. Talking to the media and involving local MPs is the only way to make a positive change take place.

    Having watched Prime Minister David Cameron's Conservative Party Conference speech today, I don't think much short of a democratic uprising is going to sway the Tories from their current, negative approach to NHS services.

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  8. Targets are not the problem. The problem is that joe public believes that all calls we go to are life threatening. Believe me they are not. The majority of the calls we go to are a complete and utter waste of time! In the papers the other day they said that 55% of people receive more benefits than they pay in tax. The culture has changed completely in todays britain where the attitude is now that if people have a problem they pick up the phone and someone comes and sorts it out for them. We actually live in a society that has fewer accidents, people live longer and have better medical facilities than our parents would have dreamed of and yet calls to the ambulance are at breaking point! Like indulged spoilt children we have always said yes to these people and they now expect more and more. The chief executive or senior management basically did not give a s**t that for the last 10 years we transported people to hospital who did not need to go in. How many of you have lugged some fat thing down the stairs, put them in the ambo,driven to hospital and before you,ve booked up they are getting in a taxi because it,s too packed in the waiting room? No, at 2am on a saturday morning while you and i are hoovering up the crap that the pubs spew out they were tucked up in their lovely warm beds (no night shifts for them of course) and blissfully unaware of what the majority of our job entails. As long as ORCON was met who cared? So they manipulate the figures, we all know that, and everybody stays off their backs and they continue to have their snouts in the trough and their apathy leads to an ambulance service that caters for those that least deserve it and fails those that deserve it most. Mr Newton has left because he realises that something is about to give and it,s better to jump before he,s pushed. Not that he,ll be sad as his pension is worth over a million pounds!

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    1. I agree with you for the most part, and I covered the sins of the public in an earlier post ( How the Public Could Save Their Doomed Ambulance Service ). However targets most certainly are part of the problem in the sense that they have distorted the priorities of Ambulance Trusts. Of course targets are needed, but as I detailed above, obsessive pursuit of response times is being allowed to directly impact on the welfare of crews and patients alike. Ultimately, this leads to worse performance and a poor quality of service because of the lack of available resources.

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    2. Targets, low morale, overwork, late finishes etc are all SYMPTOMS of the main cause! The main cause is the ambulance service is at breaking point because we send an ambulance to anybody that calls. It should be, as it was designed to be, for life threatening problems and major trauma. If the fire brigade was made to go out to anybody that called them, no matter how trivial, they would be arguing about targets, late finishes,meal breaks, missing major calls while they fixed someones fence that had fallen down!. Deal with the main cause and it will all fall into place. Why am i required to drive on blue lights to someone that have sunburn! Please can someone tell me?

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  9. Yes it's true fiqures are being fixed and cat A calls are going to triage and Cat B calls are getting an ambulance because times maybe met. RRV's are waiting upto 2 hrs as we all know, which is pretty disgusting.
    We need the support of the public and the local papers, that is the only way we are going to get the word out there and yes if we could get the local papers to run an amublance watch we could be on the road getting support.

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    1. North Norfolk resident11 October 2012 at 23:20

      North Norfolk local papers are on to it. If your papers aren't, then write to them, email them, leave messages on their web sites!

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  10. Returning to the efficiency saving theme, what has happened to money allocated for training? The one thing ambulance services traditionally provided and had a good reputation for was excellent initial and ongoing training. EEAS attitude is now that it is nothing to do with them, it is your responsibility as a registered professional to pay for your own training and undertake it on your days off.

    Does the employer not also have a responsibility? Any good employer will provide ongoing training and education opportunities for their employees.

    Get this, incredibly you now have to get permission from a manager before attending and paying out of your own pocket for some courses on your days off! What I'm not allowed otherwise? How many bloody rest days do they think I have? And on-line 'training' from home? Do they honestly think that ambulance staff want to do anything at all related to EEAS on their days off? It takes all your rest days to de-stress and recover from the war-zone of apologising for the long wait for an ambulance and the abuse you receive from frustrated relatives as you and they watch the patient deteriorate in front of you while waiting for backup.

    Oh I forgot, the one day CPD course, I'm sure when your patient is lying on a cold wet road bleeding to death waiting hours for an ambulance to arrive they will be very impressed that you know what the 'carbon footprint' of the Trust is and you have done a course in washing your hands. (Although the 'carbon footprint' of the ambulance that has had to travel from Kings Lynn to Colchester to attend them may actually be an issue).

    I think the public may be concerned that training levels are now so poor. I have recently met staff who did not know that we no longer routinely administer O2 to cardiac or stroke patients! or that you can administer aspirin to a patient on warfarin during an MI (they didn't get the memo).

    Contracts and budgets should include significant amounts for training, education and updates. It is counter-productive to fail to invest in your staff. Patient care is not about achieving the 8 and 19 minute response time with a car, especially if the clinician attending doesn't know their fundament from their olecranon.

    Get a grip and stop dumbing us down.

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  11. Latest EEAS 'efficiency' saving rumour?
    Our director of inhumane resources wants all staff wishing to undertake overtime to sign 'bank' contracts.
    Reason? They only pay plain time, not overtime rates.
    Or perhaps they are waiting for 'foundation status' for that one.

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  12. Re: Anonymous@00:09 "training in your own time" above.
    Expecting an employee paramedic working shifts to use their own money on their days off to keep themselves updated is the the equivalent of expecting a professional employee working 9-5 Monday-Friday to undertake their update training at weekends with their own money.
    I know a few GP surgeries who close for staff training up to half a day weekly.
    The reason they don't want you training is the God Orcon, they "can't afford" to take you off the road for training as they have to cover your shift at overtime rates under agenda for change.
    That's why even the one CPD training day was cancelled for many because of "achieving" response times.

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  13. On the subject of "Agenda For Change" I understood the idea was that it was a national terms and conditions agreement, NHS staff performing equivalent work and shifts receiving equivalent terms and conditions?
    So how come a paramedic or ECP working a bank holiday on the 'CSD' or 'Enhanced Clinical Triage' desk in HEOC under the same pressure to 'downgrade' all 'cat A' calls more than 8 minutes away receives a plain time pay rate, (including Christmas day) although the Nurse sat next to them doing the same job and shifts also er 'downgrading' 'cat A' calls more than 8 minutes away receives a double 'bank holiday' rate?

    When we challenged this we were told that bank holidays were taken into account when working out the percentage shift allowance - even if you are working 50% unsocial shifts! (but seemingly only if you are 'ambulance' staff).

    No I am not advocating that the Nurses lose their double pay rate for bank holidays. But I don't think 'agenda for change' intended me to work Christmas day and other bank holidays for a normal pay rate and yet I am not allowed to book leave that day (by restriction).

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  14. Is that Neil Storey in the 'sacrifice' picture above?

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    1. Perhaps he is saying "I don't see what the problem is with that".

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  15. Mat above states, In a recent document, Hayden Newton stated, “...the Trust is reporting correctly in terms of a fully equipped ambulance response vehicle deemed to be a transportable resource.” He went on to cite an unattributed quote, possibly from a Department of Health document, “the A19 target specifically precludes motorbikes and pushbikes as clearly they cannot transport patients, however nationally we do see cars being designed to accommodate patients.”

    So, from this fudge answer we can take this as confirmation that the reason we are in the shite is that we are deeming good patient care as 'achieving the 8 and 19 minute response time with a car'. The fact that this is causing patients to wait literally hours and hours for a 'real' ambulance to arrive and actually convey them to hospital resulting in deterioration, pain, loss of dignity, forcing them to defecate and urinate in their pants and possibly even leading to an early death has obviously passed them by. We can also assume from this that because response times are more important to the Trust than patient care that they are turning a blind eye if category A calls are being 'downgraded' by clinical triage if the call is more than 8 minutes away.

    The idea that a single paramedic can treat, monitor and transport a critical patient in their car is preposterous.

    Well I am calling the CQC out and asking what are you doing about it? An inquiry is required into this appalling state of affairs. Or are you going to ignore it the same as you did initially with the Healthcare Commission inquiry into "appalling care" at Mid Staffordshire NHS Foundation Trust Hospitals. It subsequently transpired that between 400 and 1,200 deaths were caused, both during and after they were 'achieving' 'Foundation' status.

    Considering the size of area and number of patients the East of England Ambulance Service is responsible for the harm caused could dwarf that number.

    Where is the government and department of health (including our local minister of state Norman Lamb) in all this? Why don't they and the CQC immediately ban ambulance services from categorising a car as an 'ambulance able to transport the patient'. Or is this appalling patient care receiving tacit approval?




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    1. Perhaps the statement from Hayden Newton “the A19 target specifically precludes motorbikes and pushbikes as clearly they cannot transport patients," should have included the line "neither can a single paramedic treat, monitor and transport a critical patient in their car but don't let that stop us saying it is an ambulance that can 'accommodate' patients so that we can 'achieve' or fiddle our response times". Also he forgot to add "but please send a double crewed ambulance if a member of my family is suffering a stroke or heart attack so that they can receive timely treatment in hospital".

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    2. Or should it have read "so they can receive timely life saving treatment only available in hospital".

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    3. Don't forget "if it's a member of MY family don't 'downgrade' the call and delay response and don't wait for the FRV to get their before sending an ambulance".

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    4. When they say “the A19 target specifically precludes motorbikes and pushbikes as clearly they cannot transport patients,"
      Rubbish, have they not heard of sidecars?

      "I don't see what the problem is with that". :)

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    5. 'Downgrading', waiting for a car to get to the patient before requesting an ambulance and using the car for the A19 response time originated a few years ago in our current director of operations county of Essex and has been exported to the rest of us.

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  16. THis will make ya laugh... Buy back annaul leave for 4 week period only, paying double time, sounds to me ORCONS must be down OR something to do with getting the foundation trust. what a joke , no money then all of a sudden it comes out the woodwork. Now they want us to have no holidays. In reply to agenda for change.
    I do believe that the ambulance service, is the only emergency service not to get inhancements for bank holidays , whats all that about, why does the goverment do that too us and not others.

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  17. Wow, this site is a revelation. Mat you are like a dog with a bone. It's like seeing "Watergate" unfurl before your very eyes! Have you thought of applying for a job on the Washington Post as an investigative journalist? (or "Panorama" or "Dispatches") You have found out more, and published it in a couple of weeks than the rest of us have in years. Maybe we should call it "Orcongate", "cargate" or "responsegate"? Any other suggestions?
    I notice the trust has refused Unisons Freedom Of Information request, reading this blog they obviously have a lot to hide.

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  18. I see EEAS has been criticised this week for their response times to stroke sufferers. How is it we are supposedly 'achieving' our response time targets for cat A calls and yet the time it takes to get stroke patients to hospital is lengthening?

    Again the answer is firstly 'Enhanced Clinical Triage' downgrading some calls inappropriately and secondly too cars 'achieving' the A8 and A19 response times but not enough ambulances to transport.

    The Trust answer is that it is due to the 'geography' of the region. This answer is laughable when one considers the audit trail that the accountants and statisticians have conveniently ignored. The audit trail being that in October 2011 the Trust was found to have quadrupled the number of patients suffering stroke or cardiac problems who were waiting over an hour (this was between 2008 and 2011).

    Obviously the 'geography' has altered considerably with all the volcanoes and earthquakes we have had in the region.

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  19. Mat am impressed with your blog. Its great everything is out there. Has anyone at work noticed that the computer has started marking " auto as At scene " ages before you get there?? When i booked mobile, Up to an hour before i got to a job last night. Four jobs in total this happened to. I assume a "glitch" in the system. At least we making orcon!!!!

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    1. I've noticed similar in the past when you are more than 8 minutes away and the screen comes up with "unit locked by another process" or something similar and you find afterwards that you were auto on scene magically before the 8 minutes was up.
      Maybe we need to record these events and datix them for when the big inquiry happens, maybe they have increased the 'in vicinity' auto locator from 200 metres to 200 miles!
      It was only an hour before you got to the job? That's quite good going currently.

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  20. I know that our colleagues in beleaguered HEOC are getting pretty cheesed off with the stacks of calls on their screens, including FRV's awaiting backup and no ambulances to respond. Hopefully some of them will be at the stage of wanting to 'whistleblow'.

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  21. Come on HEOC join the fight to save lives and tell the country what's really happening. Your the ones who can really tell the whole truth by informing QCQ, they may just listen when it's from the horses mouth so to speak.

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  22. Many staff have commented that the government and managers could not run the ambulance service worse if they tried and we are being set-up to fail in order to privatise.

    Far-fetched? Well on the right is a link to a decision by Hackney Doctors Clinical Commissioning Group (CCG) (the replacement to Primary Care Trusts) (PCT)who commission health services.

    http://www.hackneygazette.co.uk/news/hackney_doctors_go_out_on_a_limb_to_fight_government_s_nhs_reform_plans_1_1652580

    They have voted to commission only NHS providers of health services in Hackney following a report that at least 142 Peers in the House of Lords who voted for the recent Health and Social Care Bill should have been ineligible to vote on our NHS because they had interests in private healthcare providers and in effect may have voted in their own financial interest to transfer work from the NHS to their own companies because the Bill allows "any qualified provider" (or private provider) to bid for services.

    My comment is, how dare they vote on our NHS? NHS safe in your hands Mr Cameron?

    Hopefully we have no Trust board directors or senior managers with interests in private healthcare or ambulance services? But a lot of them seem to join private ambulance services when they leave or retire from the Trust.

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  23. Can anyone explain why, if we are the only ambulance available, we will shortly be made to convey patients who can be treated at home by an emergency care practitioner? With the local A&E closed the transport time will be long and we will be further choking up an already overcrowded A&E department?
    Is it because they want the ECP to achieve the next A8 and A19 target in the car? The problem is the ECP may then have to wait hours with a chest pain or stroke patient for us to transport the patient and green up at hospital. Is this a good use of resources or in the best interest of the patient?
    What happened to "Taking Healthcare to the Patient" and "Right Treatment, Right Place, Right Time"?

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  24. Returning to the theme of treating patients as you would a member of your family. Who would want a member of their family to have their 999 call 'downgraded' inappropriately, wait for a car to get there, sometimes from another county before responding an ambulance and then wait hours for an ambulance as the A8 and A19 target has been 'achieved' by the car. All because someone has deemed the car as able to 'accommodate' a patient. Or indeed be inappropriately conveyed in a car.

    I'm surprised our directors and senior managers can sleep at night. If staff in HEOC are downgrading calls inappropriately do they not fear for their registrations or criminal proceedings if found out?

    If this is occurring I urge staff to speak out before it is a member of their family.

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  25. I'm not going to comment on other trusts, but I can safely say the downgrading/upgrading of calls based on proximity of the responding vehicle is categorically something that doesn't happen in my trust. I did a third manning shift recently with a crew who point blank refused to believe me on this, and while on shift we received a call for an elderly male unable to urinate down the road from us, which came through as "Red, no AMPDS information, no further dets". Which was taken by them to be proof that this does actually happen.

    When I was back in control I checked the call and it was a green call. Spoke to the controller and he had allocated the call before it had a code (and was therefore still red - whether this is something you agree with or not is another issue altogether) because the crew was on the road heading towards the call anyway and he wanted the crew allocated before they actually drove past it as changing direction on the road is a nightmare. When the code was generated either we were onscene already or he forgot to update it. Regardless, the call was green and is reflected as such in the stats.

    I'm not saying every anecdote people have about going to red calls that are only red because the crew are next door is because of this, but it shows that there is sometimes more going on than you realise, and regardless of whether this practice does actually go on, it doesn't go on in every trust, so that's something to bear in mind when referring to "the culture in dispatch centres". Also bear in mind 99% if not all coding is done by EMDs who have no personal incentive to influence ORCON - although whether they are having pressure put on them by controllers is another thing.

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    1. EMD, I am glad to hear that downgrading does not take place in your trust. Although I notice you don't mention if your trust is waiting for the car to attend a cat A patient before responding an ambulance, or if your trust is allowing the car for the A8 and A19 transport response time?
      People can only really know how their own trust is performing. I do not know if you have such a thing as a clinical support desk or enhanced clinical triage specifically targeting the calls more than 8 minutes from a resource that have already been categorized as cat A by the EMD? That is where the problem lies and I am sure some staff will only downgrade calls for genuine reasons, but regrettably not all.

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  26. Yes, our trust uses the car for achieving ORCON targets. No, this is not the way we should be targeted. We're not the only service to be affected in such a way, either - have you seen some fire services have started to roll out their own versions of RRVs? On the emergency services panorama documentary you can almost see the Fire chief exec swallow his bile before he talks about how they're going to help the service hit their targets.

    As a rule, we don't hold calls - all emergency calls get the next available resource regardless of categorisation, within reason, and AMPDS is used in order to free up en route crews for higher priority calls.

    In my (short) experience, I have never seen an available ambulance withheld from a call because ORCON was met. In every instance the next available ambulance went out, and any time the RRV was waiting there was never a crew that could've potentially responded. Even at that, RRVs being on scene for 40mins to an hour for a patient that just need conveyed are a regular occurance. That's not through gaming the system, that's through lack of resources.

    Our clinical triage system has gone in the opposite direction and instead focuses on taking green calls and either referring them to GP/OOH/DN/Social or downgrading to urgent, when suitable.

    I have a lot of issues with my trust (who doesn't?) but I do appreciate some of the positions they take with regards to the current targets climate. Not using CFRs to stop clocks, for example.

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    1. If most of your calls get the next available resource, regardless of categorisation, then it appears your trust works completely differently from mine. They will leave 'green' calls for a 45 min to hour 'ringback' (even if the patient is lying in the road!) and will very rarely respond 2 resources (a car and ambulance) unless the RRV has already arrived and requested them. You will be surprised by the number and type of calls categorised as 'green' including most RTC's 'breathing problems', collapses ('conscious' but 'not alert') then some ridiculous decisions to downgrade patients with chest pain or stroke symptoms more than 8 minutes away. I wish we could go back to our old way of working where we went to the next call regardless. It is demoralising to wait hours for backup with a deteriorating patient or when running solo to be stood down around the corner from the patient because they are going to send an ambulance and will never want to tie up 2 resources.

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  27. Anyone know how many 'spokespersons' EEAS has and how much they are paid? They seem to attempt to defend the indefensible with statements like "we often commandeer vehicles" from the public and when one of the many complaints about delays occurs they make excuse after excuse to make it sound acceptable to leave patients in pain, deteriorating and/or lying on the ground, both indoors and out, for hours. "It was extremely busy" or "life threatening calls take priority" just doesn't wash any more. As for "that's why we want to change the rotas to match resources to the demand" I think everyone now knows what they really mean is reduce the number of double crewed ambulances even further and use more cars to get the response times but not actually provide patient care by conveying to hospital in a reasonable time. Why don't they just admit that they don't have enough double crewed ambulances already instead of believing their own bullshit publicity.

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  28. Try Asking Gary Sanderson, He's coming out with so much shit, perhaps he should remember where he started, might do him some good if he get's behind the whheel of an ambulance instead of the camera lens.

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  29. As a retired paramedic it's great to see you guy's care so much and perhaps you can answer this question for me. I have been advised by a colleague in the service that if a defibrillator and a trained user is on the premises when a collapse occurs the despatcher is allowed to record that assistance has arrived and the orcon standard met? This could still result in an ambulance taking 20 mins plus to arrive. Can you enlighten me please??

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  30. The present situation is rather more complex than this article asserts - one of the major factors that has affected the ambulance service is the abject failure of the GP system and the resultant displacement of patients onto the 999 network. I watch with interest the very MP's who not only messed up the GP service in the first place, but then went on to cut ambulance service budgets, complaining that the service has not done well by their constituents - any idiot could see that the very same MP's are the root cause of the problem ... it's all a bit like poisoning the dog and complaining that someone else did it. Of course, I fully expect the Government (which now governs very little - it's all privatized), to push the ambulance service into privatization ... think you have something to complain about now ... well, just wait and see.

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  31. Hanbridge was the best because they had excellent teachers and a very friendly and welcoming spirit. ?I really appreciate the opportunity to learn here and would recommend Hanbridge to others.



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