Dr Rachel Joyce was the PPC for Harrow West at the 2010 General Election. She is a doctor who has worked as both a Director of Public Health and a Medical Director in the NHS, and is currently a clinical adviser to a Clinical Commissioning Group.
Recently, I tended to a lady who collapsed, unconscious, at a public meeting. A paramedic in a car arrived within the target of 8 minutes for potentially life threatening calls. However, it was a further 45 minutes for the ambulance to arrive, and then there was a further delay of another 30-40 minutes before the patient was put into the ambulance and transported to hospital. The patient did not need much stabilising at the scene, so there was no clinical reason for this delay.
I regularly hear of similar occurrences, where a car arrives quickly, but the ambulance arrival and subsequent transport to hospital can take some time.
For major trauma, patients are best treated in specialist centres that aren’t always the closest A&E to their home. It has also been shown that stroke and heart attack victims have better outcomes if they are taken immediately to major centres where they can receive specialist care, even if that means a longer ambulance journey.
As described by Dr Phillip Lee MP on ConservativeHome, hospital reconfigurations for stroke patients in London has saved lives. A recent independent review of the major trauma networks set up in 2010 has shown that there has been an increase of 20% in the survival of major trauma cases since the introduction of Major Trauma Networks. As Phillip Lee says, further reconfigurations will save more lives, and this call is backed by the Royal Colleges.
These patients also need to get to the centres in the most timely fashion possible. The ‘golden hour’ in acute trauma has been long recognised – and the air ambulance services do sterling work for many of these patients.
As these improved ‘pathways of care’ for stroke and heart attack have been brought in, this has been reflected in the monitoring and performance management of times to arrival of patients at hospital and of treatment with clot busting drugs (thrombolysis) for strokes; and of treatment with coronary angioplasty for heart attacks.
However, for other patients, the time to arrival at hospital is not monitored. At least one other group – respiratory patients – appear to do better when they get hospital treatment earlier. It is common sense that other seriously ill patients would also benefit from the earliest possible treatment in the right centres.
A recent Freedom of Information Request showed that in Newark the average time between a 999 call in one area and the nearest A&E departments was almost two hours, with 10% of cases waiting almost three hours. This was blamed by journalists and campaigners on a recent A&E closure, but the reports I receive from people on the ground suggest that long times can sometimes be more a consequence of ambulance working practices than journey times – in particular focussing on the 8 minute response time rather than the time to treatment at A&E or specialist centre.
This means that for patients who have not suffered from major trauma, a suspected heart attack or stroke, paramedic cars are often being sent to reach the 8 minute target, but the arrival of the ambulance and subsequent transfer to hospital can be delayed.
The National Audit Office Report ‘Transforming NHS Ambulance Services’ review found that:
“The time taken to respond to calls has until recently been the be all and end all of measuring the performance of ambulance services. Illustrating the principle that what gets measured, gets done, the result has been a rapid response to urgent and emergency calls. However, this led to an increase in the number of multiple responses to incidents equating to millions of unnecessary ambulance journeys.”
“Over the last ten years, until the beginning of April 2011, the Department has focused on response time targets, rather than taking a more rounded view of whether cost-effective clinical outcomes have been achieved. The 8-minute response target, intended for the most seriously ill patients, is one of the most demanding in the world. However, without more direct measures of patient outcomes, its application has skewed ambulance trusts’ approach to performance measurement and management. This has led to such practices as sending more vehicles than necessary to meet the target, leaving extra vehicles to be stood down.”
The report suggested that improvements in efficiencies in the ambulance service could improve clinical outcomes, ambulance turnaround times at A&Es and even save money, and commended the work of the Department of Health since 2011 for focussing more on outcomes, which they have done in particular for heart attack and stroke patients.
The focus on clinical outcomes by this government has paid off. Improvements in the emergency pathways of heart attack, stroke and trauma patients has saved countless lives. I believe it is now time to start further work on the emergency pathways into hospital for patients with other conditions.
As the drive to improve quality and patient outcomes continues apace, there will be more need to reconfigure hospital services. For emergency patients, this reconfiguration needs to go hand in hand with changes to ambulance practices.
The evidence I receive from the ground indicates that it is now time to start monitoring and performance managing not just the time from 999 call to ambulance arrival, but also the time to arrival at hospital for more emergency patients – not just suspected heart attack, stroke and major trauma cases.