Keogh and Ambulance Services

There is much good sense in Sir Bruce Keogh’s  blueprint for urgent and emergency care across England, the latest in a long line.  It takes us back about ten years to when the Ambulance Services started to strongly develop into genuine healthcare providers rather than transporters.

The move was to imbed ambulance services into the NHS rather than have them semi attached as a kind of paramilitary adjunct scooping up casualties and dropping them off at the nearest A&E.  It was about treating patients where they were as much as moving them about. It was about getting an expert to the scene to triage what was the best response for the patient rather than sending a double crewed ambulance in response to every 999 call.  We saw the developing roles of Emergency Care Practitioners – super paramedics.  We saw that sometimes the nearest A&E might not be best and a longer journey might lead to a better outcome.  We saw ambulance service bidding to take on GP Out of Hours work and integrating the communications infrastructure.

We saw early attempts at building local databases of services available outside A&E (now the Directory of Services).  There were moves to allow even 999 patients to be taken to Walk in Centres or Urgent Care Centres which were beginning to be set up, rather than going to A&E.  Relationships were developed with Mental Health and Social Care out of hours teams and also with the then emerging NHS Direct; with collocation of teams.  We saw ideas around having extended triage of incoming calls using GPs and Consultants in control rooms and the idea that a 999 call might result in advice over the phone or an appointment with a GP.  It was about integration – now far more fashionable.

It was known then that up to 80% of 999 calls could result in satisfactory outcomes which did not involve blue lights and A&E.  It was also obvious (as least to some) that routing all other demands for urgent care through an integrated system that could align the needs of the patient to the services that were available was a good thing.  It all depended on the idea that there was a strategic view across a system with some overall governance, not a set of competing market players without any glue to make it work.

At least one ambulance service set out a strategy and consulted extensively with the public for a plan to have one single emergency care (included urgent care) system for a whole County (pop 1.5m) either through one organisation – an Emergency Care FT or through a tight network coordinated by the Ambulance Service through a single communications architecture.

Sadly what happened was that instead of vertical integration into core healthcare we got horizontal integration to make regional sized ambulance services.  This coincided with a policy shift to favour more competition generally.  The integration plan was to save money but it also ironically opened the door for the later fragmentation of emergency/urgent care.  It was a mistake, no doubt well intentioned, of historic significance.

We saw NHS leaders blaming the patients for not knowing what service they needed to contact, instead of realising that the system was incoherent.  We saw increasingly desperate attempts to promote the use of non A&E facilities like Walk in Centres to treat “minors” based on commissioner claims of cost saving and demand management which were entirely wrong.  Attendances at A&E and admissions from A&E continued to defy the optimistic claims by commissioners.

Fragmentation has continued as ambulance services lose contracts for patient transport; NHS 111 set up as a market pretty much collapses and GP Out of Hours also gets put out to competitive tender with predictable results.  The “system” is a total mess and the outcome is huge stresses on A&E Departments.

The latest Review goes some way towards recognising the role ambulance services could play but it might be a good starting point to dust off the plans made 10 years ago and implement them.