Home News Archive Publications Conferences Latest Evidence Contact Details
Background Search/ Site Map Presentations Guidelines Regional Groups Links

Regional Activity

Each regional group will report their current clinical effectiveness activity on these pages.

Wales
Last updated 18/06/01

Pre-hospital care five years hence: a personal view

Woollard, M., Ellis, D. Pre-hospital care five years hence. Pre-hospital Immediate Care. 1999;3:102-107. Reproduced with the permission of BMJ Publishing Group.

Authors

Malcolm Woollard, Welsh Ambulance Services NHS Trust, South East Region
David Ellis, Welsh Ambulance Services NHS Trust, Central and West Region

Corresponding Author:

Malcolm Woollard
Pre-hospital Emergency Research Unit
Lansdowne Hospital
Sanatorium Road
Cardiff
CF1 8UL
Tel: 02920 233651 ext. 2930
Fax: 02920 237930
Email: [email protected]

Introduction

The Ambulance Service has reached a stage in its reasonably short existence when it must take stock of the role that it currently undertakes, and identify the opportunities that exist for it to contribute more fully to health care provision. The pressures on the National Health Service are now significant for the ambulance service. This is arguably due to its increasing success in establishing itself as a key health provider through the development of paramedics and via its expertise in information and communications technology. The requirement for systems of Clinical Governance and quality monitoring; the implications of local, primary health care driven commissioning; integrated primary care services; the NHS Direct telephone advice service; and of the new ambulance response standards [1][2][3] are all necessary agenda items for the Ambulance Service to consider if it is to enhance its role. This paper represents the personal view of the authors as to how it may respond to these challenges.

Drivers for change

The public perception of the ability of the health service to cure all ills remains unshakeable, as does the belief that any new treatment or technology must inevitably be of benefit. This expectation is fuelled by broad but superficial media coverage of health related issues and through long-standing tradition.

A significant proportion of the public require that developments in the health service are provided at no additional cost to the user (no increase in taxation) and all demand that the NHS remains free at the point of use. This presents a challenge for services which are already fully utilising their resources to ensure better performance standards against a background of increasing cost pressures from purchasers and growing expectations from the general public.

There is a developing insistence that health care be provided on a local basis. This is despite the cost pressure to rationalise and centralise hospital services, driven by a need for greater efficiency and to ensure the availability at a given location of a broad range of specialist medical services. In addition, the proposed reduction in numbers of Accident and Emergency Departments, a rise in the number of individuals suffering from age-related medical and social problems, and increasing litigation awareness all impact on how the ambulance service must organise itself for the future.

The response of the NHS

The recent white papers ‘The New NHS. Modern. Dependable’ [4] (England) ‘Designed to Care’ [5] (Scotland) and ‘Putting Patients First’ [6] (Wales) emphasise the role of General Practitioners and other primary health care providers in defining the shape and direction of local health services and provide a framework for change.

Cost pressures and progress in technology and pharmaceuticals have resulted in the development of the clinical effectiveness initiative. [7] This aims to move health care towards evidence-based practice to ensure that any service development can demonstrably improve patient outcome. Whilst a reduction in mortality is one simple measure of a positive outcome, reductions in morbidity, hospital admissions, bed occupancy duration and improved quality of life are also of significance. This initiative has in turn resulted in an increased emphasis on the role of clinical audit, [8] both in determining whether staff are compliant to clinical protocols and, more importantly, whether these protocols produce the desired patient benefit. The advances that ambulance services have made over recent years suggest developing clinical audit links with acute and community services would enhance the holistic approach to health care provision.

Ultimately the importance of evidence-based health care, developed from best practice, has been emphasised by the emerging concept of clinical governance. This places the responsibility on the shoulders of Chief Executives and managers of Trusts for ensuring that high standards of patient care are delivered. In this regard the white papers detail the formation of two significant organisations: the National Institute for Clinical Effectiveness, which will be responsible for establishing National Service Frameworks, and the Commission for Health Improvement, which will have the responsibility for monitoring the quality of services provided to patients.

The drive for greater efficiency in the face of rising demand has resulted in increasing pressure to target resources across a limited front. In a small number of high profile cases this has led to rationing or restrictions in the services that Health Authorities choose to provide locally. Certainly, the emphasis is gradually shifting away from patients having a right to choose how and where they access the health service. An alternative is a system of triage, utilising professional expertise, to ensure patients receive the right level of care, in the right place, within an appropriate time frame, and according to their clinical need. [9][10] The NHS Direct telephone advice service pilot sites provide a working example of this latter approach. Their original aim was to reduce inappropriate requests for out of hours GP visits and accident and emergency department attendance. [11] This concept has rapidly evolved and it is now envisaged that NHS Direct will become the gatekeeper for all access to health services to ensure that, from the first point of contact, only that type of care will be utilised which can most efficiently resolve a patient’s problem.

The white papers and the green paper ‘Better Health, Better Wales’ [12] emphasise the importance of self-help. This change in the culture of society must be guided and supported through initiatives such as the NHS Direct advice service.

The opportunities and implications for the Ambulance Service

Primary care providers will form the lead bodies that determine the future shape and type of health care provision. Whilst the ambulance service has always been perceived as a component of the secondary care system, when the nature of the work it undertakes is examined this view defies common sense. The ambulance service is the first point of contact for over seventy percent of the ‘emergency’ patients which it transports,[13] the bulk of whom request assistance for medical and social (rather than injury-related) problems. The remainder of the emergency ambulance service’s workload consists of requests for care and transportation from GPs who have themselves visited patients with an acute or exacerbated chronic condition in the community. Whilst the non-emergency patient transport service is currently contracted for by secondary care providers, much of its outpatient workload is also generated by GPs. It can, therefore, be argued that the majority of the work of the ambulance service is linked firmly with primary care.

It is vital that the ambulance service capitalises on these links in order to expand its role. As the first point of contact for upwards of seventy percent of the emergency patients it transports its staff determine where these individuals are taken to. Currently, almost all are transported to Accident and Emergency Departments mainly due to a lack of suitable alternatives. Two independent studies show that at least half of the patients admitted by ambulance as a result of a 999 call are discharged with no referral. [14][15] Whilst these studies review admissions to accident and emergency departments serving inner city areas, the authors would suggest that their findings are generalisable to most hospitals, at least as an indicator of a trend if not in absolute terms. Greater integration with primary care providers would allow for joint development of agreed clinical guidelines, providing ambulance staff access to a range of primary care services and skills; supporting transportation of patients to alternative locations (such as out of hours surgeries or minor casualty units); referral to appropriate agencies for home-based care; or allowing ambulance staff to ‘treat and release’ patients [16] (see figure 1).

Text Box:
Figure 1: Outcomes of on-scene triage by ambulance staff

Such an approach risks shifting some of the financial and resource burden from secondary to primary care. However, it would also mean less patients being unnecessarily transported to accident and emergency departments. This would free these facilities to meet rising demand, and allow the ambulance service to target its resources more effectively to those patients with the most urgent medical need. [17] In rural areas ambulance transport times to fully equipped and staffed accident and emergency departments can exceed thirty minutes, resulting in the vehicle and crew being out of their operating area for over an hour. This has implications for response standards in that area and brings pressure to increase resourcing in areas of low demand, to facilitate response time targets being met. However, if the many patients who do not require the resources of a fully equipped A & E could be treated locally, this would keep ambulances closer to their normal area of operations and result in shorter journey times. It would also free up these expensive resources more quickly to respond to the next call. This  thinking is emphasised in the recent value for money study undertaken by the Audit Commission, [18] which recommends that a sensible step may be to assess emergency calls and provide a range of responses that recognise patients’ differing needs. This will be dependent on more research, education, multi agency working, and investment in communications technology.

Whilst such a strategy may provoke concern amongst GPs regarding potential increases in their workload, this could be offset by a number of additional proposals. By working closely with GPs to develop telephone triage protocols, it will be possible to reduce the number of house visits made by GPs to patients who are subsequently admitted by ambulance to hospital. Instead these patients could be identified as requiring a the immediate attendance of an ambulance  alone, reducing the cost arising from a dual response and freeing the G.P. for other work An extension of this approach may involve the provision of appropriately skilled ‘community paramedics.’ These could, on a GPs behalf, attend selected house calls to conduct initial triage and communicate the results back to the physician, thus allowing the patient to be directed to the most appropriate form of care.[19] This would require close co-operation between ambulance services and GPs and could, perhaps, be best facilitated via the provision of tele-medicine links (see figure 2).

Text Box:
Figure 2: Managing G.P. workload.

There is some limited evidence that G.P.s are prepared for paramedics to undertake this work on their behalf.[20] Undertaking such a role would, however, require an extension to the current paramedic education programme in order to provide staff with the under-pinning knowledge necessary to effectively fulfil this task. It could be argued that community nurses already have the skills needed to perform this function. An alternative view would be that, if the patient has a condition requiring immediate advanced life support, paramedics could provide this as part of their normal skill base. This would not, in most cases, be true for community nurses. It could also be argued that district nursing services are already over-burdened and that, particularly in rural areas, are under-resourced. Ambulance services have ready access to the expertise and infra-structure necessary to establish the communications link with G.P.s that would form a vital part of this proposal. Further, a number of paramedic degree courses are being implemented around the UK, some with nursing input, and these could be utilised to fill the identified knowledge gap.

It will be particularly important to continue the development of joint out of hours services. Not only have these markedly reduced home visits by GPs, they have also formed a sound basis on which to explore how links between ambulance services and GPs can be exploited in the interests of all parties, and particularly to the benefit of patients. The ready availability of out of hour surgeries will potentially reduce inappropriate attendance at Accident and Emergency departments and demand on the 999 ambulance service. Provision of transport to such centres by non-emergency ambulance vehicles forms a vital (and cost effective) part in ensuring easy access for those patients who do not have the financial resources to provide their own transport, or for those who are medically unfit to utilise other types of vehicle.

Particularly in rural areas the ambulance service has the potential to fill gaps in absent or under-resourced community nursing services. Additional training (and most importantly education) for paramedics would enable them to provide the clinical care which, by its current absence, mandates that patients are resident in hospitals rather than at home. Clearly, there is a risk that other primary care professions may feel threatened by such proposals and this can only be eliminated by joint development with these groups.

The ambulance service also has the ability to provide community based services that until now have been provided by no other group. For example, it is common for a non-emergency ambulance in a rural area to be tasked to transport patients to a haematology service some forty miles away, simply to allow blood samples to be obtained. It would make greater economic and social sense for a paramedic to visit each patient at home, take blood and transport the samples to the laboratory. This would have the added advantage of ensuring that this paramedic is available for emergency responses in the area they serve. Similar principles could be adopted for the checking of newly applied Plaster-of-Paris splints, or the monitoring of patients discharged home with minor head injuries. Again, it could be argued that community nurses may also undertake these tasks. Clearly, however, in those areas where these patients are being transported to hospital for such checks, they are not doing so. As has been argued previously community nursing services are already stretched, whereas ambulance services, particularly in rural areas, do have spare capacity. A critical number of ambulances must be dispersed across any geographical area in order to ensure reasonable response times to the local population. In rural areas this requires an economic balance to be struck between response times and utilisation rates. Fewer ambulances mean higher utilisation rates and lower costs but longer response times, and vice-versa. Subsequently, there is spare capacity in rural areas, and strategies such as the one outlined here could increase utilisation rates without jeopardising response times, provided the crew are only tasked to work within an appropriate area. Rapid response paramedic units, positioned in rural areas to facilitate achievement of the new ambulance response standards, will inevitably also suffer a low utilisation rate. Adoption of additional ‘Community Paramedic’ duties as described here will assist in making such units far more cost-effective. Tele-medicine may contribute to this development in allowing paramedics to access specialised clinical guidance.The medico-legal implications of paramedics assuming additional clinical skills must be carefully considered. These initiatives, and proposals for the introduction of triage protocols allowing non-transportation of certain patients, will require the development of clinical judgement. This can only be achieved through an evolutionary advance in the selection and education of ambulance staff.

Managed health care

The key to enabling patients to obtain the right level of care, at the right facility, within an appropriate time frame, according to their clinical need, and regardless of the time of day when they seek help, is the rapidly evolving NHS Direct telephone service. Logically, this should fit naturally into the role of the ambulance service, given its current expertise with emergency triage systems and communications technology. However, whilst the ambulance service is a natural choice to provide the infrastructure, this type of facility must be staffed by nurses utilising established protocol-driven decision support systems. This helps to reduce the risk of inappropriate triage decisions being taken [21][22] and the subsequent threat of litigation [23][24] Such systems can, however, be effective in reducing the workload of G.P.s [25] and in particular the number of home visits they make. [26] This type of service is popular with both G.P.s [27] and patients. [28] The White Paper’s principles of integrated care, improved partnership arrangements, and the elimination of competitive contracting will aid in overcoming barriers to the implementation of such integrated systems.

Acting as the first point of patient contact and as a link between service providers will enable the ambulance service to expand its role as a provider of telecommunications services. Ready access to patient data and voice communications from remote sites will become of increasing importance to carers. This in turn will require the development of a single patient record allowing simple but secure access for a wide range of health care professionals. The use of the NHS patient number will be integral to achieving this aim and as such the ambulance service must explore its utilisation as a component of its own patient records.

Health maintenance

Inevitably, funding will be linked very closely with projects that are directed at meeting health gain targets, [29] and the ambulance service should actively seek opportunities to expand its role in these areas. Whilst the potential for ambulance trusts to contribute to reducing deaths from heart and respiratory disease, deliberate self harm, and accidents is clear, they could also become active participants in the health promotion arena. Fire Brigades have been very successful in reducing the incidence of fires through the provision of public education, premises inspection and advisory services. A similar role could be developed for ambulance services by working with health promotion experts to provide public education in accident prevention and initial medical care, inspecting commercial premises to monitor arrangements for first aid, and offering advice to a range of private and public bodies on the provision of equipment, training and personnel. This could be further expanded, in co-operation with other health care professionals, to include walk-in clinics at ambulance stations where simple checks could be offered. These might include blood pressure and cholesterol measurements, and provision of advice on correct diet, exercise regimes, and how to stop smoking. Clearly it would be necessary to involve health economists in the development of proposed changes and it is not suggested that such a service could be financially viable in all areas. However, in rural locations, utilisation rates for ambulances are low and the use of standby points is less appropriate, as stations are situated in small towns with long distances and very low populations between them. Subsequently, rural stations are often ‘staffed’ for long periods of time. And in urban areas, the station itself may provide a useful resource which other health maintenance workers may wish to utilise from time to time.

Clinical effectiveness

Whatever initiatives are implemented, in order to attract funding for developments and to maintain current services it is vital that clinical effectiveness is demonstrated. The ambulance service must build on its initial work in clinical audit to provide clear evidence of what does and does not influence patient morbidity and mortality. This will require the development of links with hospital information systems to determine how the treatment initiated in the out of hospital phase effects a patient’s eventual outcome at and beyond discharge. Audit is only able to determine if existing treatment protocols are appropriate, and a sound research and development program will also be essential in testing alternative models of care for patient benefit and cost effectiveness. [30] A clinical effectiveness program provides an ideal basis for benchmarking performance and provides an opportunity for the development of more relevant contracting currencies.

One outcome of a clinical effectiveness and audit program will be the development and constant revision of care pathways which define not only the clinical intervention to be provided, but also the optimum time points at which these interventions should take place and the most appropriate disposition for the patient. [31] Definition of critical time points for each clinical intervention will result in a gradual differentiation between the care provided by rural and urban ambulance staff. For example, the well researched requirement for early administration of thrombolytics may require that they be given in the ambulance in rural areas when journey times are prolonged. However, in urban areas, where travel times are much shorter, these drugs may be more appropriately administered in the Accident and Emergency Department. Care pathways, jointly developed with a broad range of health care providers, would also aid in ensuring that patients are managed where it is most appropriate. Insulin dependent hypoglycaemic patients need no longer be automatically directed to an Accident and Emergency department. In one review, it was found that in excess of forty percent of hypoglycaemic patients who recovered following paramedic initiated treatment subsequently refused hospital admission. [32] These patients currently risk falling through the primary health care monitoring net. However an appropriate care pathway would require the attendance of a nurse specialist from the GP practice after paramedics had corrected the blood sugar level. A similar approach could be implemented in the management of confirmed epileptics who have had a single uncomplicated fit in the out of hospital environment. Such an approach has the benefit of freeing ambulances more rapidly, thus reducing pressure to increase resourcing to meet higher demand and new (more challenging) response standards. It has the advantages of avoiding unnecessary journeys to hospital for patients and keeping the primary care system informed about adverse events, ensuring appropriate care is provided in an integrated and timely manner.

Hospital care

The reduction in junior doctors working hours also provides an important opportunity for the ambulance service. Paramedics already possess some of the simpler technical skills practised by junior doctors, such as intravenous cannulation and management of cardiac arrest. Secondment to appropriate hospital departments may be supported by the medical profession in reducing their burden. This would provide an ideal opportunity for paramedics to enhance their existing skills, particularly if they are normally based in areas with low call volumes. It would also allow ambulance staff the opportunity to develop additional skills relevant to an expanding role in primary care, such as patient assessment in the non-acute situation and clinical interventions such as urethral catheterisation.

Organisational structures

Structures must support the current and developing roles of the service and the key measure of quality of care. Individual staff are the final arbiters of the quality of service provided, and so the responsibility for measuring and correcting this should be positioned as close to the provider level as possible by creating clinical supervisors. Local monitoring of the manageable components of response times, such as crew mobilisation and hospital turnaround times, coupled with supervisor-led clinical audit and peer review of patient management strategies, will be essential in building quality systems.

Staff must become increasingly flexible as they undertake new roles. In order to encourage co-operation and active participation it will be essential to place responsibility for determining working conditions at the lowest possible level. For example, whilst logisticians will determine the number of ambulances necessary to meet the call demand for a given time of day, the team of staff responsible for staffing each vehicle should be allowed to determine their own shift patterns to match this resourcing need. Tradition and archaic working practices must not be allowed to inhibit change.

The organisation of middle management must reflect the structure of the emerging primary-care led health service and geographical areas of responsibility are therefore likely to have boundaries in common with those of Primary Care and Local Health Groups.

Conclusion

The implementation of the strategies in this paper will enable the ambulance service to contribute more effectively to health care provision by increasing its integration with primary and other health care services (see figure 3).

Text Box:
Figure 3: A Model for Patient Flow in an Integrated Out-of-Hospital Care System

It is recognised that these proposals will have a significant impact on educational, communications and operational activities. However failure to adopt a progressive and proactive stance in developing the role of the ambulance service risks its true potential being overlooked by commissioning organisations. This is not to say that the ambulance service should seek to supplant existing health providers, but rather to find ways in which it can complement or contribute to their role. This paper has also described a number of gaps in current service provision that the ambulance profession could potentially fill. A lack of clear evidence demonstrating the clinical effectiveness of current ambulance service models and treatment protocols jeopardises maintenance of funding levels in the future, as cash becomes increasingly limited and purchasing priorities are directed to other areas of the health service. Indeed, the real danger is that funding for current paramedic training and service developments may become restricted and that subsequently the ambulance service will devolve once more into a transport organisation.

Acknowledgements

The authors gratefully acknowledge the contribution provided by Dominic Ellett and two anonymous reviewers in improving the first draft of this paper.

References

[1] Chapman R, et al. Review of Ambulance Performance Standards: Final Report of the Steering Group. NHS Executive 1996.
[2] Department of Health DGM (96) 162. Department of Health 1996
[3] Welsh Office. DGM (98) 29. Welsh Office 1998.
[4] NHS Executive. The New NHS. Modern, Dependable. The Stationery Office. 1998.
[5] Scottish Office. Designed to Care – Renewing the National Health Service in Scotland. The Stationery Office. 1997.
[6] Welsh Office. Putting Patients First. The Stationery Office 1998.
[7] Hine, D. et al. Towards Evidence Based Practice. Welsh Office 1995.
[8] Hine D. et al. Framework for the Development of Multi-Professional Clinical Audit in Wales. Welsh Office 1996.
[9] Calman K. Developing Emergency Services in the Community. UK: NHS Executive 1996.
[10] Royal College of Physicians Working Group. Tackling NHS Emergency Admissions: Policy into Practice. UK: The NHS Confederation 1997.
[11] Crouch R, et al. Ringing the Changes: Developing, Piloting and Evaluating a Telephone Advice System in Accident and Emergency and General Practice Settings. Kings College School of Medicine and Dentistry 1996.
[12] Welsh Office. Better Health Better Wales. The Stationery Office. 1998.
[13] Department of Health. Ambulance Services, England: 1997/98 Statistical Bulletin. UK: Department of Health 1998.
[14] Pennycook AB, Makower RM, Morrison WG. Use of the Emergency Ambulance Service to an Inner City Accident and Emergency Department – a Comparison of General Practitioner and ‘999’ Calls. J Rl Soc Med 1991;84:726-727.
[15] Volans, AP. Use and Abuse of the Ambulance Service. Pre-hospital Immediate Care 1998;2:190-192.
[16] Ellis D. Integrated Paramedic Care – a Vision for the Future. British Journal of Health Care Management 1998;42.
[17] Audit Commission. A Life in the Fast Lane. London: Audit Commission 1998.
[18] Audit Commission. A Life in the Fast Lane. London: Audit Commission 1998:66.
[19] Woollard M. Emergency Medical Dispatch and Prioritisation. J Brit Assn Immed Care 1995;18(3):47-52.
[20] Stephenson J, Cooke M. General Practitioners Overestimate Paramedic Skills. Pre-hospital Immediate Care 1998;2:75-76.
[21] Crouch R, Dale J. Telephone Triage – How Good are the Decisions? Nursing Standard 1998;12(35):33-39.
[22] Rupp RE, Ramsey KP, Foley JD. Telephone Triage: Results of Adolescent Clinic Responses to a Mock Patient With Pelvic Pain. Journal of Adolescent Health 1994;15:249-253.
[23] Edmonds E. Telephone Triage: 5 Years Experience. Accident and Emergency Nursing 1997;5:8-13
[24] Zautcke JL, Fraker LD, Hart RG, Stevens JS. Denial of Emergency Department Authorization of Potentially High Risk Patients by Managed Care. Journal of Emergency Medicine 1997;15:605-609.
[25] Gallagher M, Huddart T, Henderson B. Telephone Triage of Acute Illness by a Practice Nurse in General Practice: Outcomes of Care. British Journal of General Practice 1998;48:1141-1145.
[26] Christensen MB, Olesen F. Out of Hours Service in Denmark: Evaluation Five Years After Reform. BMJ 1998;316:1502-1505.
[27] Lattimer V, Smoth H, Hungin P. Glaser A, George S. Future Provision of Out of Hours Primary Medical Care: a Survey with Two General Practitioner Research Networks. BMJ 1996;312:352-356.
[28] Gallagher M, Huddart T, Henderson B. Telephone Triage of Acute Illness by a Practice Nurse in General Practice: Outcomes of Care. British Journal of General Practice 1998;48:1141-1145.
[29] Welsh Office. Caring for the Future. UK: Welsh Office 1994.
[30] Culyer A. Supporting Research and Development in the NHS. London: HMSO 1994.
[31] Welsh Office. Putting Patients First. UK: The Stationery Office 1998
[32] Jones T. Unpublished data. South and East Wales Ambulance Service NHS Trust 1997.