Blame, Private Ambulances and the Cost of Lives

Last Summer, a diligent individual documented as “P. Holmes” made a Freedom of Information request for East of England Ambulance Service to release a breakdown of payments for private ambulance contracts in 2011 and 2012.

According to this website, earlier this month the figures were finally released [with thanks to Anonymous for the tip-off].

Apr  £310,733
May £363,945
Jun £1,062,006
Jul £348,630
Aug £735,142
Sep £863,450
Oct £623,676
Nov £889,098
Dec £758,754

Jan £980,042
Feb £908,579
Mar £1,016,571
Apr £539,169
May £788,091
Jun £604,922
Jul £932,795
Aug £1,090,099

Total: £12,815,702 over 17 months

This works out to an average of three-quarters of a million pounds (£753,864) every month. That's £9 million every year. It is interesting to note that, over 5 years, that expenditure makes up most of the £50m the Government require the Trust to save over the same period.

Are Private Ambulance Services Worth the Money?

Is having private ambulance firms waiting in the wings an efficient use of limited Trust funds? If there was some logic to the application of these private services then perhaps. If calling in private ambulances was a temporary measure whilst the publicly-funded Ambulance service bolstered its own cover then it would be more agreeable. Or if they were being used for routine transport to free up front line emergency resources. But there is evidence to suggest that none of these possibilities are the reality.

If these nebulous private services were being used appropriately and accountably, there might be less cause for concern, but that is not the case. According to the correspondence provided by EEAST, this is the “total monthly PAS [Private Ambulance Service] spend on Emergency & Non-Emergency services”.

What is the most worrying about this is that accounts from front line paramedics who have encountered private ambulance staff at the scene of emergencies, have found them to be evasive when challenged on their skill sets. (An example of questionable private ambulance professionalism can be found at the Trying My Patients blog.)

The title of Paramedic is protected by law and can only be worn by those who are registered with the Health Professions Council - a regulatory body who enforce stringent standards of  “training, professional skills, behaviour and health”. As such, ambulance attendants with lesser skill sets, as usually found on private ambulances, have vague titles on their otherwise similar uniforms that will confuse the general public. One account from front line staff even found a solo private ambulance attendant first on scene at a serious emergency to have a limited command of the English language.

A lack of clear skills and ability to communicate is dangerous – if a front line professional cannot be clear on the abilities of those attendants around him, then there is increased risk to the patient, especially as the struggling system is relying on these individuals to replace the service currently provided by registered professionals.

The cost of these private ambulance crews is reported to be more than three times that of the Trust equivalent – a Trust paramedic crew on triple time would apparently still be cheaper. Yet elsewhere, Trust paramedics working permanent relief – where they get very little notice of when and where they will be working – are now being made to audit their shifts and if they are not assigned 60% antisocial hours by the admin staff then they will have their pay incrementally reduced by up to 25%.

Even more frustrating to Trust front line staff is the knowledge that these private crews are paid for an entire shift but are only called upon if Trust resources are unavailable, meaning that while Trust crews are repeatedly denied a break, somewhere an expensive private crew is probably sitting idle.

I'd like to be clear: this is not the fault of the crews on either side of the line, but the poor decisions that created the line in the first place. The questionable deals and arrangements that allow this siphoning of funds to take place need to be thoroughly investigated.

Illusion and Delusion

The expenses listed above date back almost two years and gradually increase up to the most recent entry in August 2012. This suggests a pattern of growing reliance on external private resources. All the while the Trust have been building a case for reducing ambulance cover.

EEAST Interim Chief Exec. Andrew Morgan
Of course, it is also important to note that the Trust delayed releasing these figures for several months and they are conveniently old enough for the current Chief Executive to blame the previous incumbent. I'm sure that they have an explanation waiting in the wings to detail how they are no longer spending this much and how things are now much rosier.

But the new regime has already shown its colours with their truth-distorting claims of 15 “extra ambulances” and “a recruitment drive for 75 new paramedics and 124 emergency care assistants”.

As those of us watching quietly from the sidelines already knew, this turned out to be smoke and mirrors. Old vehicles left unmanned due to staff shortages were requisitioned from other areas also struggling for cover, then refurbished and relocated. The incoming staff are to fill existing vacancies as more experienced staff leave for roles that won't lead to an early grave. The entire press statement was spin engineered to placate the public and the press.

EEAST's motive was to stem the recent tide of bad publicity which they seem convinced is the root cause of poor staff morale. In their press statement of 5 February 2013, which they released in response to coverage on BBC Look East, the Trust claimed that “ of those key issues raised by crews was low staff morale directly because of recent adverse press...” 

What an appalling attempt to sidestep responsibility for looking after their own staff.

They blame not the fact that the staff are routinely abused by their employer and the general public, not the disruptive, gruelling nature of a job made worse by inadequate resources and poor management and flawed policy, instead they blame "adverse press" coverage – the fact that the failings of the service, ergo their management, have become public knowledge. They think that's why entire ambulance workforce is buckling? Seriously? If the people in charge are really this deluded, the problem is even worse than previously feared.

For the benefit of those senior personnel who seem to be struggling with unfamiliar concepts: what you are experiencing is shame. Front line staff are well versed in dealing with the ignominy of having to publicly apologise for a failing service, it's something they've been doing for some time in their daily dealings with real people.  Their morale hasn't suddenly dropped, it's been steadily drained over years. Perhaps what ambulance leadership has started to become aware of is a sudden decline in their own morale as the propaganda bubble burst and reality started to creep into the board rooms and conferences. Shame is likely an unfamiliar sensation to them and they should be advised to reflect upon it and consider taking some responsibility rather than blaming the media/public/staff/other scapegoat.

The Political Shadow

The sad truth is that all this evidence suggests there are forces at work with agendas that place profit and bonuses above patient care and ethics. I don't for a minute expect the East of England Ambulance Trust to suddenly reform and deliver a "high-quality cost-effective" emergency ambulance service - those are just buzzwords they'll fire out in press releases to convince those who are not experiencing the opposite on a daily basis. EEAST just don't have the resources, even if they were spending more sensibly. The only thing that will change is the direction of the spin.

But EEAST's position is just a symptom of a far greater disease. I don't care for politics – but there is no escaping that this is a problem of government policy. Ambulance Trusts around the country are all facing the same decline; just as EEAST tried to convince their region the problem was exclusive to Norfolk rather than face the truth that the failure to deliver was region-wide, it is in the government's interests for the country to believe this is only an East of England problem rather than a national one. It is all a public image damage limitation exercise and was the only thing EEAST still had any real control over, but now they're losing that battle too. However, the government will still claim black is white and there is no cause for alarm.

It is the direction of the current government which dictates the policies and purse-strings to which NHS Trusts must adhere. In the current climate of economic austerity, it seems that we are also making savings on morals and ethics. The message from the Prime Minister at the Conservative Party Conference in October was very much a case of “every man for himself”. The concept of helping others is anathema to their agenda of helping people to help themselves.

Whilst society does have its parasites and those who would take more than they give, it seems that those individuals exist at both ends of the fiscal spectrum. But does this mean we should just accept that we now exist in a society where we abandon the weak?

Ethics? Morals? Health? Lives? Only if we can afford them.

The future is money.

I am ashamed to be part of it.