ࡱ> C  !"#$%&'()*+,-./0123456789:;<=>?@ABRoot EntryF )c*MatOST`rc*`c*MMMN0:}ND FMicrosoft Works MSWorksWPDocSii$P2(k:}y::ypy-yyy z;ppA.-Fy&k{y2DzTResponse to Delivering Modern Ambulance Services Copyright -  FOR PUBLICATION Page  A response for Reconfiguration of AMBULANCE TRUSTS South East Region A time for Foresight not a Vision British Ambulance Services (Foresight) Panel 19-21 Bassenhally Road Whittlesey, Peterborough Cambridgeshire. PE7 1RN Phone Number +0044 (0) 1733-350916 Fax Number +0044 (0) 1733-350112 Date 13th August 2001 Table of Contents Part Background Page 3 Part FORESIGHT Summary Page 3 Part Introduction Page 4 3a Statement of Problem/Need Page 4 3b Project Scope and Objectives Page 4 Part Identified sections Page 5 4a Ambulance Functions on a Regional scale Page 5 4b Creation of greater local operational management Page 6 4c Provision of greater volumes of service Page 7 4d Current Trust thinking not in line with Public Expectation Page 8 4e Future Public expectation has been over emphasised Page 9 Page 10 Part BASP Conclusions Page 11 BACKGROUND We are making a formal response to the NHS Executives document Delivering modern ambulance services in the South East Region of the NHS The NHS Executive published in May 2001 a consultative document based on The Vision of eight Ambulance Trusts Chief Executives and Chairmen requesting comments to be returned by September 2001 In the past such consultations have resulted in no changes from the outlined and recommended outlines, despite public objections or individual comments. This in the past has resulted in a ramrod approach by the Governments servants and advisers. We contemplate no changes, unless the Secretary of State decides to intervene, and put right, past mistakes in consultation, by taking more notice of tried and tested experience. This document is intended to be a Public record, that will be used as a published example should the past ramrod approach be continued by the NHS Executive. However it can also be used as a tool for providing subjective change, by taking into account broader established views based on tried and tested methods that have and continue to work effectively FORESIGHT SUMMARY Foresight is about anticipating future problems, it is about breaking down barriers to collaboration across business sectors, it is about presenting key issues and responding to those issues for quality of life in the 21st century. The intention is about co-operation, not conflict, and to also provide a new set of visions and a fresh agenda for action, in order to enhance the UKs ability to meet the challenges of the future, and take full advantage of the opportunities identified. In 1999 The Government stated they wanted to achieve the widest possible range of inputs to this consultation in their statement they said The Focus is squarely on wealth creation and quality of life, on tackling issues that matter to people and business, identifying what might be done to address these and doing it. In 1999 The British Ambulance Services Panel was formed as an associated DTI Foresight programme to anticipate the future by identifying potential needs, threats and opportunities, in all ambulance service operations, and to take action now to ensure that people and organisations are better placed to respond effectively This document is about those principles and is in response to NHS proposals for change. It is to the benefit of the Public and the NHS that this document be considered and acted upon by all concerned in any future proposed changes in NHS Ambulance Services INTRODUCTION The printed proposal refers throughout to preferred options, based on the leaders of the Ambulance services in the South East Region who have created a joint vision of their role in the future. To deliver their vision, the ambulance services will work with others in the NHS and Social Services to agree how appropriate 999 callers can be safely directed to, and cared for by, one of the new alternative services when their needs would not be best served by Hospital Care However the continual reference to the Trust Chairman and Chief Executives Vision can only create added concern when based on past performances. A Vision defined by the new English Dictionary is The power of seeing a supernatural appearance, A revaluation, imagination, mental concept, something seen in a dream or trance. This vision is badly lacking in actual foresight based on any tried or tested methods. BASP would advise the NHS Executive and Secretary of State for Health to reconsider the proposals, as they may not be the best way forward, when judged on past performances, and the continued inability to meet with even the simple duties that have been given for them to undertake as County services. Statement of Problem/Need NHS Ambulance services do need Reconfiguration, they do need to change their working practices, and they do need to revise how they will meet with future demand, by reducing the needs of the general public and by providing an appropriate response. This will not however be achieved through the introduction of larger services, additional services, or increased attendances through fast response units, or possible referral to other Health provider services, who themselves may not have spare capacity. Project Scope and Objectives The scope of this document is to provide food for thought, through objective appraisal by the BASP panel within the time limits allowed, based on past experience and sound tried and tested methods of Ambulance working. We have not been given a year to look at these proposals as have the NHS Ambulance Trusts involved. Its objective is to give guidance to both the NHS Executive, The Secretary of State for Health, and others, so that they will be more aware of the threats and the opportunities that present themselves through this current proposal based largely on a sceptics Vision. We hope to be able to identify potential problems, and possible opportunities to put matters right, so as to provide a futuristic service, that will have greater ability to cope, it will require radical change, but change for the better, based on worldwide tried and tested experience. ACTION PLAN The document of Vision has identified a considerable number of existing problems in NHS Ambulance Services, however the methods proposed to rectify those continuing problems are not necessary the solution, and if some of the proposals are undertaken they will but increase the problems beyond all proportion, and the services will deteriorate even further, and this will be of even greater Public and Governmental concern than it is today. We have identified a number of important points and believe that: The provision of Ambulance functions on a larger regional scale has not been proven. The developing of greater local operational management, is not proved The provision of greater volumes of service by Ambulance Trusts is not proved We conclude that Current NHS Ambulance Trust thinking is not in line with simple Public Expectation That Future Public Expectation has been over emphasised in order to expand operations. Ambulance Functions on a Regional Scale The first regional amalgamation of County Ambulance Trusts, Cornwall, Devon and Somerset has not worked, it is amongst the poorest performing Ambulance Trusts in the UK. This was followed by the Amalgamation of Cambridgeshire, Suffolk, and Norfolk, which after substantial additional investment continues to perform poorly compared to the individual County performances before such amalgamation. This has been followed by amalgamations of Nottinghamshire, Derby, and Leicestershire into EMAS., and Northumbria and Durham, followed by Teeside, North Yorkshire and Humberside, all have failed to provide improved services, or any cost savings that had been indicated in the proposals. London the original regionalisation of London, Middlesex, and parts of other counties is the poorest performer, and continues to have substantial amounts of scarce NHS funds thrown at it, with very little effect, and many have resigned themselves that it will never meet with the targets that have been set. This problem is far greater a challenge than the new proposals. When a written report was made to the London Service Inquiry on how the problem could have been solved some years ago, the government of the day decided to ignore the solution, as at the time it would have seemed very radical, it however provided a solution to the present Home counties problems This proposal was for Regionalisation with a significant difference. A copy of the proposals are in the House of Common Library as they were submitted by PAS Ambulance Consultants, on the orders of the investigating committee. The Panel Chairman and author of the report considers that they are as relevant today as they where when submitted, and the Minister may wish to consider those proposals again, as they would be relevant in solving many current problems in the South East Region. The Creation of greater local operational management Pyramid building in the NHS is not something new, and each Government has attempted to reduce management and increase the service end of operations. Over the years all that has happened has been increases in unproductive manpower management by other names. Throughout industry and Public services, top management are paid on responsibility based on Budgets managed and staff numbers. The bigger the organisation the larger the salaries and benefits for the Directors. The bigger the organisation, the harder it is to find people with the experience to control the Company or organisation. But is bigger better ? can local management be decisive in large Trusts ? will Trust Boards who are held responsible allow local management to make decisions that may have greater effect on the overall Regional operation ? The truth is it has never been allowed to work in the past, local management has been suppressed in all regions, the local management have become disenchanted and have left, leaving great gaps in the lines of essential experience needed in Ambulance Services. Promotion in many cases commands little additional salary, and usually involves extensive travel away from the established family home, or the uprooting of the whole family for short periods of time, whilst the experienced manager becomes more involved with carrying out the orders of the Directors, or having to attend meetings day after day to discuss every small detail of yesterdays working. Experienced Paramedics are handing in their boxes and reverting to Technician status, or are just leaving the service after very many years of valuable experience, as many of the middle and senior management attempt to put their or their Directors own individual stamp, by changing tried and tested methods in preference for a whim fancy or desire to do things differently. Management in a Regional Ambulance setting has not worked, and it would be better to have a simple county based service, that is consistent with all other Health Trust and County Council reorganisation that has been recently undertaken, so that local management and local ambulance controls can meet with local needs, manned by local experienced staff some of whom may no longer be operationally fit to undertake extensive front line duties. Indeed a recent foresight report on the ageing population predicts that in 10 years time all organisations are going to have severe recruitment problems as the more experienced elements are lost to early retirement or ill health produced by extensive extension of duties. Localisation needs to be established as early as possible in order to meet with this threat to the recruitment structure, otherwise experience will be lost and services will decline still further. We suggest that at least a ten year plan should be established. The Panel advise and advocate greater localisation and reductions in regionalisation within all Ambulance Services in order that NHS Ambulance Services are better placed to respond more effectively and to meet the current and future threat of loosing experienced staff through inability to relocate due to increased family commitments, and future greater potential recruitment problems, as already identified by the DTI Aging population Foresight panel The provision of greater volumes of service by Ambulance Trusts There is a misconception that Public expectation requires ambulance services to provide greater volumes of service. We have found that NHS Ambulance Trusts have since inception busied themselves, on expansion plans in order to enlarge budgets, and maintain increased staffing numbers, in order to provide additional financial returns to the senior management. In 1993 PAS Ambulance Consultants published a report A need to review and reform the NHS Ambulance Service. This report included a return to the Basic concept and setting of standards, based on Public and others Expectation of an Ambulance Service. It was not acted upon by the Government of the day, and since 1993 the basic service has deteriorated, as NHS Ambulance Trusts expanded into other areas of Medical provision, and indulged in income generation, to the detriment of their core duties of transportation of The treatment and transportation of sick and injured persons, from Public places. That 1993 concept maintained both the 1948 and 1954 NHS principles of the provision of free Ambulance transportation to or from a place of treatment for: Any person who has suffered an accident in the home or a public place, Any person who is suffering from illness in a public place, Transport for any expectant or nursing mother to or from a place of treatment Transport for any person in medical need, who cannot travel by any other means, Attendance of an emergency ambulance in 50% + of cases within 8 minutes in town, Attendance of an emergency ambulance in 75% + of cases within 14 minutes, Attendance of an emergency ambulance in 95% + of cases within 19 minutes, Arrival at hospital for out patient treatment within 1/2 hour of appointment, Departure from hospital after appointment within 1/2 hour of end of treatment Ambulance provision for discharge from ward, anytime within 24 hours of notification, Attendance of Emergency ambulance within one hour of call or before for Doctors Urgent, All emergency ambulances to be crewed by qualified experienced staff, All Patient transport ambulances to be crewed by qualified experienced staff, Ambulance services are to be engaged whole time on ambulance provision only, Supply of Ambulance & Ambulance Aid services at cost effective charge rates for private and other functions and requirements (will depended on standards being met) The above was the simple Public Expectation in 1993, from more recent surveys we have concluded that this simple Public expectation has not changed, and we see no future need for any immediate change to provide any greater volumes of service, that are advocated within this and other NHS documents. Current NHS Trust Thinking is not in line with Public Expectation Public expectation is based around more localised services, yet current NHS Ambulance Trusts thinking is based around Regionalisation. The public conception is clearly based on past service provision which worked, which is relevant to County based and run services, such as the Police, Fire Service, and County Councils. Indeed as long ago as 1966 Miller advocated County based services organised on a National standard in order to provide a uniform and consistent service throughout the UK. That principle has not changed. The Police and Fire Services have reviewed concepts of Regionalisation and are discounting such moves, and the NHS itself is currently focused on areas based on existing County Council borders having tried smaller Trust units which proved to be uneconomic, yet NHS Ambulance Trusts are departing from this now realised concept that has been tried and tested, and has been found to work as the most economic unit for at least 150 years The NHS Ambulance Trusts argument is that they are facing increased demand, and need to introduce new technologies, that they have to train and motive staff to higher levels, and they have to collaborate to improve the infrastructure and maximise resources available for patient care Within their submission they relate to benefits of scale, but they expect no savings in relation to fuel costs the trusts biggest non-pay expenditure But they do expect to minimise costs through joint procurement such as vehicles, uniforms, and equipment purchased. The 1966 Miller report addressed all of these issues, and up until 1990 there was a degree of standardisation for Vehicles, Uniforms, equipment, and training. But since the inception of NHS Ambulance Trusts, those economies have been lost to the Health Service. County Councils as long ago as 1960 established central purchasing facilities for all Local authority organisations. The NHS itself established an NHS procurement division, yet many NHS Ambulance Trusts failed to agree to National Standardisation or specification, and went ahead with vast changes in uniform, equipment, and vehicle standards and preferences based mainly on individual Trusts whims, fancy or desires, rather than on sound management principles based on the scarce economics available and National Purchasing. All the proposed savings can be achieved without Amalgamation and the proposed additional costs to the NHS can likewise not be incurred saving the NHS some 2.6 million plus. The expenditure of 7 Million to support the introduction of Electronic Health records is not essential as Ambulance records are passed on direct at the time the patient is handed over, at the Hospital and remains with the patient , BASP cannot see any reason why the existing system used cannot be continued, and any administrative cost then placed direct to patient care, unless this cost is related to NHS direct a non-ambulance function that many Trusts have become involved in. Future public Expectation has been over emphasised by NHS Ambulance Trusts Many NHS Ambulance Trusts believe that they should be involved in all aspects of Health Care by providing supernumerary services such as Doctors Drivers, Paramedic Response Units, Paramedics in Casualty Units, Bus services, Social Transportation, Private Ambulance Services, Helicopter Air Ambulances, Patient Transport Services, mail delivery services, waste disposal services, furniture delivery services, NHS Direct, pagers, telephone and communication systems, telephone answering services for Doctors, Nurses, Social services, Vets, and the Water and River Authorities. They also believe that the Public and others in the NHS expect them to provide these services at whatever the cost in order to complete against private contractors, and to maintain this as a National Health Function in order to fully utilise the assets currently available to many NHS Ambulance Trusts. From BASP investigations the Public expect nothing more than an quick attendance of a Road Ambulance in a time of urgent need, and this has been born out by ambulance staff, and other Health Service workers. The Public do not care if the Ambulance is sitting in an Ambulance Station, and that the crews are just drinking tea and watching the television, as long as when they are needed they arrive without any delay, they are a service as are the Fire Service and should be used and manned on an in case of situation not a because of or maybe situation Ambulance services cannot function without the actual Ambulance Crews or Ambulance Controllers, when NHS Ambulance Trusts expand operations into other areas it reduces the availability of essential staff from the core functions and duties of Public expectation. Some recent examples in one Trust, they set up 8 Paramedic response cars, and transferred 8 front line Paramedics from front-line Ambulances to man this operation in a attempt to improve response times. During a twelve week period one Paramedic worked a 10 hour day, and during the total twelve week period attended only 3 (three) incidents, during the rest of the period he sat at stand-by points throughout the County, in the other cases the same patten emerged, and 7 of the Paramedics have returned to front-line duties where they feel of more use. they have been replaced with 7 other Paramedics which has then placed a considerable strain on the Ambulance availability, and these ambulance crews continue to work non-stop throughout a 12 hour shift, in many cases without a meal or refreshment break, due to crew shortages and sickness, as they are diverted from one job to the next. This is a prime example of it works elsewhere, so it must work here attitudes from Higher management and it becomes a desire to implement a simular service. In another Trust they decided that they needed a Helicopter Air Ambulance costing 1 million per year, and they needed it 7 days a week. Yet in the past two years they only needed a helicopter on five occasions, this was provided by the military at no financial cost to the Trust, However if they had have been charged the total cost over two years would not have exceeded 75,000. To justify its existence it is sent out on a regular basis and out of 79 calls it has only conveyed 20 patients to hospital, and most of those was due to non-availability of Road Ambulances. It is suggested that this expensive facility is simply being used to reduce the attendance times on 3 missions a day conveying just 0.6 of a patient at a cost of 4,166 per patient journey, and a cost of 2,739 to sit on the tarmac, It cannot fly at night or in inclement weather conditions. It also ties up Land Ambulances in many cases at both ends of the flight, and in a recent statement the manager said We now need to make sure the money keeps coming in to keep it up in the air permanently Many Ambulance Service Trusts have become involved in NHS Direct, involving Nurses and Paramedics in telephone diagnosis in an attempt to reduce demand on both the Ambulance Service, A & E departments and Doctors Surgeries. Telephone diagnosis is extremely difficult and with some 50 + staff engaged in some of the NHS Direct posts, it may have provided better value to man some 25 extra ambulances with the Nurses and Paramedics and sent the Ambulance to the patient, as in most cases the ending get out advice is if you remain worried, see your GP or go to A&E. When an appropriate attendance of the G.P. or an ambulance if the G.P. cannot be contacted would in all probability cost no more money that being spent at present. All that NHS Direct appears to do is draw in experienced staff from front-line duties, creating shortages in these areas. We also have drop in medical centres, that have been positioned in town centres at considerable cost, yet they could provide a better service and more economical service, that would have allowed for staff interchangeability in times of shortage if they had been positioned next to, and integrated with existing A & E Departments. In the BASP panels experience we have only seen a few examples where a Dedicated Helicopter Air Ambulance would be possibly needed. Cornwall servicing the Scilly Iles, Hampshire servicing the Isle of Wight, Scotland servicing the Highlands, and Islands, and Wales. In most cases if the calls and injuries where analysed there would be very little Medical need for such services, and it is not a cost effective solution but more a waste of donated and public money resulting in reductions of service in other essential areas of simple public expectation The involvement of staff in most of these projects of fancy needs justification not only on the grounds of cost, but also on the grounds of Medical need, when in the vast majority of examples a prompt attendance of a G.P. or front -Line Land Ambulance with a qualified crew of two would be both more economic and suit the patients medical needs. The panel would recommend that the Secretary of State for Health and the NHS Executive instigate an independent inquiry into the greater economic use of all NHS Ambulance Resources, so that future funding can be placed and used to provide best value for medical need, and so that Front-line and other crews can be used to the patients best advantage, in order for simple Public Expectations be full filled. BASP conclusions The Chairman and The Panel are of the conclusion that the proposed amalgamation should not be endorsed by the Secretary of State for Health. or the NHS Executive as it is a vision not based on foresight, but on a dream that could become an expensive reality, with NO visible improvements It is noted by the panel that it is different to other Amalgamations in that in this proposal it does not advocate any cost savings, instead in advocates additional costs to the NHS in excess of 2.6 million, and we are not convinced that it will solve any of the prevalent or future problems of the individual services concerned, other than higher paid management. None of the past Ambulance Trust amalgamations have shown any results of success or savings that they predicted before amalgamation, and expert opinion is very much towards a return to County based Services that actually work, which will fit with the recent NHS re-organisation of mirroring County Council borders. The other Emergency Services Police and Fire have reached the same conclusions during their review of borders. The Ambulance Service problems are not confined to the proposed eight counties, reorganisation of Ambulance Services in the South East of England must also include London, and the Northern Home Counties in order to solve todays problems and address many of tomorrows potential problems. A potential answer through radical change was published by PAS Ambulance Consultants and was submitted as evidence to the House of Commons select committee of investigation into the London Ambulance Service, a copy is held in the House of Commons Library, and this document should be consulted before any changes are made to other Ambulances services around the capital as it may have further relevance to any future reorganisation proposals, as it offers a solution to many of Londons, and the Home counties continuing Ambulance problems. BASP have examined Public expectation of Ambulance Services, and the Ambulance Services proposal does not address that expectation. The NHS Executive and the Secretary of State for Health are requested to examine the subject of Public Expectation, and BASP propose that the executives should take note of its simplicity, and perhaps instruct all Ambulance Trusts to comply, and withdraw from other activities which distract essential resources from that prime objective of providing Free Ambulance Transportation to those in need. Peter A. 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