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...