Primary Care in the Ambulance Service

Primary Care Urgent Care

Demand has grown for the Ambulance Services by 35% since 2010. While the government announce that the budget has seen a 16% increase in budget since 2010 (National Audit Office, 2017), in reality matching inflation counts for 12% of this increase. This demand is not predominantly the ‘living longer effect’: while that of course does play a part, aging is largely a predictable variable and with effective planning could have been corrected for many years ago. The increase in demand comes largely from four areas: undifferentiated urgent care complaints; failed secondary care; mental health problems; and social care problems. All the above have occurred as a response to the cuts seen in Primary Care, Hospital, Mental Health and Local Council budgets. In this first of a series of articles, we will focus on the effect of cuts to primary care and the shift from GP provision to Ambulance provision as a result.

Ambulance services
Ambulances outside the Accident and Emergency Dept

During this article, I will refer to urgent and primary care interchangeably. This is because the classification for ambulance is ‘urgent’, where many of these patients should be managed in primary care. Many of the concepts of which I speak here are not the subject of research. I have linked to evidence where possible, but much of what I say comes from personal experience, and from talking to other ambulance clinicians around the country.

The Ambulance Services used to deal with, largely, emergency care. The perception of this remains, but it masks the true nature of today’s Ambulance Service. A mobile GP surgery, with none of the equipment, training or support. Older paramedics reminisce of days gone by where they only went to “genuine calls” – heart attacks, respiratory problems, road traffic collisions and cardiac arrests. Today, these make up only a small percentage of call outs. Today, we go to a variety of calls from mild belly ache, urine and chest infections to “baby won’t settle”, months-old complaints of back pain and other primary care conditions.

While this may appear on the surface as misuse, and therefore an issue of public ignorance towards the severity threshold for a 999 call, as many clinicians and social media users alike will propose, there are underlying processes at work that socialists must examine.

Many patients will talk on crew arrival of the immense difficulties they have undergone to try to get an appointment with a GP, only to either be instructed to call 999 as the surgery, under immense pressure themselves, are unable to assess the patient within a safe timeframe, or to be told the nearest appointment is in 3 weeks, to which many concerned relatives will see no choice but to seek a quicker assessment – and none are quicker than the ambulance service, despite increased waiting times. Others have been referred by the 111 service which has a notorious infamy amongst ambulance clinicians for referring a large number of false positives – and missing false negatives.

Some may reply that if Ambulances are sat around waiting for emergency calls, and GPs are overstretched, then we should be available to help. While I shall deal with the issue of the need for a ‘reserve’ within the ambulance capabilities later on in this series, it is also important to examine how we deal with these primary care cases.

At no point do Emergency Care Assistants, Emergency Medical Technicians, Associate Ambulance Practitioners or even Paramedics receive training in the management of urgent or primary care cases. Our guidelines make no provision for it either. Our assessment training only covers so far as to identify conditions that fall under the Emergency remit (Strokes, heart attacks, pulmonary embolisms etc.). Due to the lack of training, many do not have the confidence to make decisions on primary and urgent care cases, fearful of missing an atypical heart attack or other hidden emergency condition and such like. Alongside the perception of lack of support from employers and regulatory bodies (which does not always align with the evidence), this leads to an inordinate number of conveyances to A&E “just in case” – and not always in the patient’s best interest.

Our assessment equipment, again, is tailored to emergency situations – electrocardiograms, blood sugar tests (in case of an unconscious diabetic), oxygen saturation probes – and we lack the necessary equipment to make primary care decisions. For example, “Dipping” urine is a very simple skill, no more difficult than a litmus test or an old pregnancy test, such that relatives and patients are sometimes taught to use it. However, paramedics are unable to “dip” urine, with no explanation given (one can only assume a cost factor), needing for us to rely on District Nurses, GPs and A&E to conduct the urinanalysis, delaying diagnosis and treatment for a common elderly condition, which can progress to life-threatening sepsis if left untreated.

Not only this, but we carry only enough medication to prolong or save life in emergency situations – adrenaline, salbutamol, and morphine among others. Even if we correctly assess the primary or urgent care complaint, we have no management tools. We carry no long-term antibiotics (and maybe for good reason with a view to antibiotic resistance, but it has implications if we are to respond to these jobs). We can offer nothing for long-term pain management (only enough to move an in-pain individual to hospital). Again, with GPs unable to fit in appointments, this leads to a large number of conveyances to A&E as ambulance clinicians (rightly) view it as unethical to delay treatment, even if A&E are over-stretched.

The biggest problem caused by ambulance response to primary care is the lack of emergency reserve. I personally have heard so many calls from the Control Room pleading over the radio for someone to make themselves available to respond to hyper-time critical emergency events like choking, fitting or cardiac arrest, because the closest crew is 20 minutes away being drafted in from another city. Amongst other causes of increased demand (mental health and social care), this is because closer ambulances are dealing with primary care conditions. A major source of stress for ambulance clinicians is knowing you’re only a few minutes away from a time-critical emergency, but being unable to leave the primary care patient you’re currently dealing with.

However, there are advantages that are appearing as the ambulance profession absorbs primary care into its remit. An obvious example is care for patients who are unable to leave their home due to current or past medical conditions or their age. Traditionally dealt with by visits by their GP, these patients are left without care out of hours (except by out-of-hours GP visits) and struggle to ever be seen by health care professionals due to cuts to both in-hour and out-of-hour GP provision. A more detailed argument would be required by someone with experience in GP Primary Care provision dealing with whether home visits are an efficient and appropriate use of a GP’s time (as opposed to other HCPs). Ambulance clinicians are traditionally mobile and used to working in people’s homes, and are now used to dealing with some primary care complaints, could be one alternative. Before the Ambulance Service merger, Staffordshire Ambulance Service conducted GP Home visits on behalf of many surgeries, and provided the out-of-hours provision. This was backed up by training, good local working relationships, equipment and a more advanced management portfolio than the one provided to clinicians in the same region now.

Another advantage is that paramedics are more regularly exposed to emergency patients than GPs, which gives them skills and experience that would assist GP assessment and to start the pre-hospital management of emergency care. One example of such a skill is that paramedics are fast becoming experts in 12 Lead ECG interpretation, and with this skill being almost routine, paramedics would be well placed in GP surgeries to provide an additional experienced opinion. Cardiac arrests are an uncommon occurrence within a GP surgery, and no matter how well a clinician knows the theory and has memorized the protocols, the management of this condition is difficult out of hospital, especially for clinicians who don’t have regular exposure to it. This is another example where ambulance clinicians who have a lot of real life, hands on experience with out of hospital cardiac arrest, would help primary care providers deliver effective care.

The two competing processes of dealing with urgent care and emergency care represent a tension that at times, such as winter, represents a crisis. In simpler terms, Ambulance Services struggle to provide a timely response to emergency care by being tied up in urgent care, and, as society’s last line, leave urgent patients without access to care due to dealing with higher priority requests (e.g. reports of elderly ladies left on the floor for hours).

So, what is the solution?

First and foremost, GP surgeries require sufficient funding to make sure no-one waits an unethical amount of time for an appointment. If Ambulance clinicians are to respond to primary care calls, clinicians should receive the correct training, equipment, management tools and support from GPs to provide the right care to the patient.

However, no amount of amelioration will resolve the contradiction. One set of resources balancing the two types of care will always be only one disturbance from crisis, no matter how well balanced it may appear.  What is appearing as the most fundamental requirement of any solution is that exclusive pools of resources to deal with each category of demand is required.

To achieve this, Emergency Ambulance Services should not take responsibility for responding to these primary care/urgent calls, and responsibility should pass to another group of resources. Possible splits could be for emergency care to pass to the fire service, or for urgent care to be taken up by the 111 service. It would also be possible for a split to occur within the ambulance service, much how the Patient Transport Service or the High Dependency service operates separately from Emergency care.

However, my suggestion is instead for non-emergency ambulances staffed by specialised urgent/primary care paramedics with the necessary equipment to be attached to individual GP surgeries, with a good working relationship with the surgery staff, that can carry out home and urgent visits at all hours. For clinical governance purposes, they could be managed by a national non-emergency ambulance organisation, while being paid and employed by the GP surgery.

The reasons I believe this to be the correct solution are:

  • Continuity of care for patients with acute exacerbations of chronic conditions, which is good for both the patient and helps clinicians make good decisions
  • Ambulance Crews are able to access a patient’s medical records to make informed decisions
  • A good working relationship between ambulance clinicians and GPs is difficult to achieve in many urban areas, due to the large number of regionally employed ambulance crews and the multitude of localised GP surgeries, however, one must only look to community paramedics based in rural villages and their relationship with the local GPs to see the increased benefit for the patient and the wider NHS.
  • A clear delineation between Primary/Urgent GP care, Emergency Ambulance Care and Secondary Care, where currently the lines are currently very blurred, allowing for correct training and equipment.
  • An embracing of the advantages of ambulance clinician primary care

The Socialist Health Association should oppose any attempt to load further primary or urgent care on to Emergency Ambulance Services – either directly, or indirectly through further GP cuts. The SHA should recognise the internal contradiction and its effect on patient care, and to call for primary care provision to return to GP services, allowing emergency ambulance services to have crews available to respond to true emergencies. However, the SHA should embrace the positives of mobile primary care response units and the unique experience of ambulance clinicians and call for ambulance clinicians to become more involved in primary care provision in GP surgeries through a number of possible mechanisms.

James Angove is a pseudonym. The author is a socialist and a paramedic in the UK, whose identity must be hidden due to the treatment of health care professionals and other whistleblowers who talk about issues within the health service.