Who Cares for the Carers?

Last week, I was invited to speak at the NHS Pathways National Partnership Forum, a gathering of 111 providers, clinical commissioning group representatives, technicians and policy-makers who are focused on improving the telephone assessment service. I took the opportunity to offer some insight into the 'view from the trenches' in support of encouraging an evolution of the system toward a more positive and effective working relationship between 111 providers and ambulance services.

This is the transcript of my presentation (along with some of the slides).

Good morning, my name is Mathew and I work as paramedic clinical advisor at Herts Urgent Care - 111 providers for Hertfordshire, Cambridgeshire and Peterborough. 

The reason I've been invited to speak today is because earlier this year I made some impact in the mainstream media in an attempt to address some widely perceived misconceptions about the 111 service. It is my hope that I might also be able to provide you with some insight into the complex relationship between Pathways-trained clinicians and our frontline brethren.

So I'd like to take this opportunity to share with you some of my thoughts and experiences relating to that, from my perspective as a 111 operative, a former frontline ambulance clinician and in particular as an active user of social media.

You see, I'm in a fairly unique position as a result of a few unexpected twists and turns in my paramedic career. If you'll indulge me, I'd like to give you a little background.

After more than a decade as an emergency ambulance clinician, I retired from frontline service in 2012 due to a spinal problem which - at the time - left me with some mobility problems and quite significant pain. As I recovered slowly at home, the time gave me the opportunity to start a blog, the Broken Paramedic, which enabled me to address and discuss concerns and issues that affected the ambulance sector.

Well, I say I 'took the opportunity', in truth, it was my Mother who convinced me to redirect my blogging experience to challenge growing fears about ambulance cover in her locality of North Norfolk, which had already been suffering from a poor level of service and was facing a further reduction in ambulance cover. Ultimately, common sense prevailed and the level of ambulance cover was actually increased.

I was surprised by the impact of my first few blogposts and I soon found myself being invited to write an 'expert opinion' column in the Daily Mail's campaign against A&E closures. 

Since then, the Broken Paramedic online presence has grown organically into something of a loose community comprising allied healthcare professionals and interested members of public, which continues to cast a critical eye on many aspects of the ambulance sector - and associated primary care interests, often quite ferociously. Contributors certainly don't always agree.

I've been able to challenge some of the more dogmatic aspects of ambulance culture, and to give a voice to those who might previously have been silent. For me, one question keeps popping up: who cares for the carers? 

It has also given me the opportunity to work with various other media outlets and documentary teams, including a number of radio appearances and even a brief visit to the red sofa of the BBC Breakfast studio.

It was in August last year that, for various reasons, I applied for the role of 111 clinical advisor in my home county of Hertfordshire.

I think it's safe for me to say now that - as well as being curious - I was, like many of my frontline colleagues, a little suspicious. My time out on the road at East of England Ambulance Service had left me with a disdain for anything that I perceived to be causing unnecessary pressure on increasingly beleaguered ambulance staff. In my time, this was an accusation often leveled at NHS Direct, our own dispatch, the ambulance management, the Trust board, the government, the public. Sometimes it was justified. Sometimes it wasn't. But in any case, it was no surprise to me that contemporary staff were pointing the finger at 111. 

The experience of working in emergency pre-hospital care shapes you. In many ways this is a good thing, helping to develop clinical knowledge and the soft skills that working in such a varied and challenging environment requires. But in other ways it causes damage. For most normal humans, it's just not possible to sustain a consistent levels of empathy, clarity and tolerance for 13, 14, 15 hours of consecutive emergency calls.

So I approached my new role with some trepidation, acutely aware of the fact that I was signing up to be the primary scapegoat for my former colleagues and my readership.

As I grappled with the concepts of telephone triage and using the Pathways tool to support my clinical assessment I started to see the similarities between and the differences from my former frontline role. 

The differences were obvious; I now do a lot more sitting down (which is great for a dodgy back), and I encounter far fewer traumatic sights and strange smells (notwithstanding the occasional peculiar lunch choice from the next cubicle). I've not once had to find a change of clothing halfway through a shift. The hours are a lot more predictable too.

But there are similarities. The emotional reward of spending some time helping somebody who is struggling to cope in some way is something I had missed during my retirement. But now as a clinical advisor I get this dopamine hit far more frequently than when I was on the road - my rate of positive interactions can now be upwards of 5 an hour rather than a few times a shift.

The oddest similarity, and perhaps given the focus of this forum, most relevantly, is that Pathways is essentially my new crewmate.

Ask any ambulance roadstaff and they'll tell you that your crewmate is of critical importance to your working life. How you work together to get the job done defines what the patient, your crewmate and your own self takes away from the experience. There are ideal crewmates and there are those that are... less than ideal. I've had both. I've been both.

It's that buddy-buddy relationship that has been the focus of so many Hollywood movies and I think the chapters of every ambulance clinician's career are defined by the crewmate they had. Of course, I went on to marry one of my crewmates, so perhaps I'm biased.

In any case, Pathways has big shoes to fill. (I'm not saying that my wife's got big feet or anything, you know what I mean).

This is the professional relationship that empowers your clinical decisions, that keeps you on track when your focus drifts, that comes up with that genius insight that hadn't occurred to you. This is what Pathways is excellent at.

Of course it's also the working relationship that provides moral support when things aren't going well, takes over if you and the patient aren't quite connecting, and knows how you like your coffee. Pathways is absolutely terrible at that. 

Over the last year, my relationship with Pathways has evolved, and it's been an education. It's often been the reliable, no nonsense Sherlock to my empathic but meandering Watson. It's grown from a slightly jarring, forced interaction into a productive, effective relationship, despite Pathways' tendency to railroad the conversation and interject with ridiculous requests ('no Pathways, I'm pretty sure this elderly, bed-bound dementia patient hasn't been to West Africa in the last month').

I soon came to realise the importance of the work we do at 111 and the impact it has on primary care, particularly the emergency ambulance sector. I realised that some of my more frustrated frontline counterparts were getting things wrong.

They're not wrong to be frustrated with their lot - I know how it feels to be stretched thin, used and abused and squeezed to the point of broken exhaustion on a regular basis. They're not wrong to identify when a 111-generated emergency ambulance response turns out to have been inappropriate to the patient's needs. They're certainly not wrong to identify that there is room for improvement – of course, there is.

But I believe the are missing the mark to lay the blame on 111 staff or the service as a concept. My experience of a functioning 111 call centre has been diametrically opposed to the horror stories the likes of the Daily Mail has portrayed in recent months. Day in and day out I see good people working hard to provide an informative, empathetic and professional service which the demand clearly shows that the public wants and needs.

Which is why I felt it was important to leverage the social media platform I had built to challenge the misinformation peddled by some mainstream media outlets and to address the concerns of my ambulance brethren.

With Herts Urgent Care's endorsement, I was able to use my media contacts to provide an alternative view in The Metro, which was well received and widely read to the point that I was approached by ITV News to provide a counterpoint to their prime-time story on concerns being raised about the safety of the 111 service. It is my belief that much of the concern arises from a broad misunderstanding of the service provided and the limitations, both among the general public and, it turns out, some healthcare professionals.

Following on from that used my Broken Paramedic blog to tackle some myths and misconceptions that persist among ambulance staff.

This was generally met with a conciliatory tones of understanding and agreement from my ambulance readership, although some concerns raised are valid and worthy of further consideration – particularly with regard to the information which is or isn't passed from Pathways to ambulance dispatch to attending crew. And of course there are always a few who are just too angry to hold a conversation with. 

But I didn't come here just to say how great I think 111 is - there are some uncomfortable truths that need to be faced by 111 providers, ambulance trusts and the general public. Absolute safety cannot be guaranteed nor should it be promised. Healthcare just doesn't work that way.

But I don't think we should be shy about showing how safe and effective 111 currently is, nor should we back away from discussing how it can be improved.

The growing call demand that 111 and 999 services are experiencing is evidence of the public's faith in both. However we need to foster greater faith in each other.

Some of my most rewarding work is when I successfully identify cases Pathways wanted to send an ambulance to which can be safely downgraded. Some of the most frustrating moments are when I have no choice but to send an ambulance on safety grounds, knowing that in all likelihood the attending crew will be silently cursing my name for wasting their time and unnecessarily adding to their exhaustion.

It would be of great benefit for both of these kinds of cases to be part of a better communication between 111 providers and ambulance services, but not at the committee level – at the grassroots level. If my clinical assessment could land on the screens of the attending ambulance crew to explain the reason for their attendance, I think a lot of hearts and minds could be won. Equally, if the attending crew had a better way of sharing their findings with clinical advisors, then all parties would learn and feel part of the same team – which we absolutely are.

Ultimately, I signed up as a 111 clinical advisor, not only because I wanted to return to helping the vulnerable and the infirm, but because I wanted to do something to help my ambulance brothers and sisters. I genuinely believe that as well as being an advice service for the general public and the gatekeepers of primary care service, we are the guardians of the well-being of our frontline colleagues.

After all, who is in a better position to care for the carers if not us?