In the bleak midwinter…

Social Care

Every winter, the crisis of care deepens. Here we are, in the eye of the storm, with the contradictions glaring out from the abyss. 10+ hour waits at A&E, causing countless unreported harms in delayed treatment. It’s upsetting to think soon, someone is likely to die in the corridor, just as last year (The Guardian, 2017)

The infamous Corridor is usually where patients are taken by Ambulance when they are unable or unsafe to walk (e.g. the bedbound, the nursing home resident) or when their condition requires continual assessment & management (e.g. amber-flag sepsis, breathing difficulties on oxygen etc.), but are not life-threatening (heart attacks, strokes, etc.). When the Ambulance Triage bay is full, patients queue on beds on Corridors, waiting to be moved into the bays and triaged. With hospital staff unable to safely care for the numbers on the Corridor, ambulance staff remain with the patients until able to handover. Ambulances parked at A&E cannot respond to life-threatening calls. Not only this, I have seen colleagues waiting 2 hours beyond the end of their already long 12 hour shift (and remember, we usually do 4 in a row, and many are now on 6+), unable to go home due to A&E delays. This has a massive impact on morale and fatigue, and subsequently, the care that clinician is able to give.

The question may be asked: If the corridors are full of patients brought in by Ambulance, why are Ambulances overloading A&E? This is the question I wish to address in this article.

On top of the everyday demand of people who are genuinely ill and require A&E admission, it is possible to point to categories of Ambulance/A&E patients that don’t require admission and therefore, are contributing to the crisis on the corridors. No, I’m not talking about drink or drugs.

The first one is the policy of Residential and Nursing Homes (I’ll refer to them collectively as ‘care homes’) to outsource medical care to the state, despite residents paying in the region of 4 figures per month for care. Rather than invest in falls prevention and staff trained in health assessment (such as Advanced Nurse Practitioners, Paramedics or Emergency/Urgent Care Practitioners), many homes state that carers must call 999 (some are generous and allow for 111 – which usually results in an ambulance in any case) for any medical condition – emergency or not. I have personally been to numerous 999 calls (and 111 referrals) for simple coughs, colds, chronic pains, or low energy falls or slips out of bed with no injury. Often, by the time we arrive, the resident is soundly asleep, and receive a surprise awakening at an uncivilised hour to have Ambulance crews poke and prod for a short time, hopefully without shipping them off to A&E.

In this way, care homes absolve themselves of any financial responsibility towards the medical side of a patients care (except in nursing, where medications and some care is given, but no health assessment, diagnosis or management which requires further training).

As a Paramedic, it is my opinion that the NHS is indirectly subsidising privatised social care, with the proceeds going into care home profits, with no incentive to reduce the bill to the state, and no incentive to invest in prevention.

Why would a capitalist invest £100k/year+ in a team of Paramedics to provide care within the home in order to prevent drawing on the state’s resources, or invest in falls prevention, with no financial incentive to do so? I stand wholly for the re-nationalisation of care homes into the NHS system. However, while we blindly hang on to a mixed system, it is important for the NHS to look at charging care homes for state resource use, thereby incentivising investment in preventative care. This will, of course, introduce its own corruptions and contradictions – an incentive to not call 999 may put genuine patients at risk, for example. This illustrates that incentives are merely a plaster, and nationalisation is the only cure.

Research has been undertaken to understand the medical picture in care homes (Smith et al., 2015), and they correctly point out that care home patients have more complex needs than the average elderly population, requiring more admissions than average. However, they miss the underlying profit motive for over-engagement with emergency services, and the reasons for high conveyance rate by Ambulances to A&E.

The Mirror (2018) recently reported that ambulance conveyances had risen 62% from Care Homes since 2010. This will be partly a function of the aforementioned increased engagement with emergency services. However, to understand why there is a high conveyance rate from Care Homes by Paramedics, many of which are for ultimately non-emergency conditions, one must understand that Paramedics are formally trained only in emergency conditions – those that go to the ‘Resuscitation’ area of A&E. We pick up the non-emergency conditions as we go along, but that doesn’t make for confidence in discharging on scene. Combine that with a culture of fear imposed by management in the Ambulance Service, especially the fear that a wrong decision could see you sacked, and you end up with conservative medicine, and a large number of nursing and residential home residents in the Corridor at A&E with non-emergency conditions.

A similar process plays out as a result of a computer triage system employed by 999 and 111 with inherent vulnerabilities that cause a large number of ambulances to be sent to the same non-emergency conditions in the community (More in depth analyses of this issue can be read here and here). Without training and confidence to discharge without further care, and when alternative pathways are closed or oversubscribed, they end up in the Corridor at A&E.

When the Ambulance Service is being flooded, the first place one must look is how we manage the floodgates. A computer has not made an adequate gatekeeper, and clinicians must return to the role in order to correctly manage demand.

Many alternative pathways being closed is another major factor in large numbers of conveyances, leaving paramedics isolated and without choices for safety netting. Paramedics, despite the lack of training and the fear, try incredibly hard to refer to other services if possible. A ‘Safety Net’ allows ambulance clinicians to feel more comfortable discharging on scene. Long established services have been closed due to CCG budget cuts. Also, many new trial alternative pathways are introduced during office hours, when most remaining services (such as patient’s own GP) are already open. Unsurprisingly, these are undersubscribed, and are often closed soon after. The problem doesn’t disappear during office hours – it is incredibly difficult to get a same-day GP appointment – but it is especially prominent out-of-hours. It is during the night and on the weekend when ambulance clinicians are left isolated, and it is easy to see why many take the safe option of conveying to A&E.

The Corridor is a result of a perfect storm: Emergency Ambulance Clinicians being sent to non-emergency calls without the correct level of equipment, training or support, left without a suitable alternative pathway, in the face of media attacks and fear of repercussions from management, are practicing conservatively and filling up A&E Corridors.

To stop the Corridor Catastrophe, the Socialist Health Association should stand for:

  • Renationalisation of Care Homes & the rolling out of Health Assessment staff and falls prevention schemes. In the interim, a charge to the Care Home should be placed on Emergency Service contact. Both should result in lower 999 engagement, and more preventative medicine investment, lowering the number of conveyances to A&E.
  • The reintroduction of ambulance clinicians with medical support as gatekeepers to the 999/111 system, abolishing the use of computer triage. A well trained Ambulance Clinician on the phone with adequate support will be able to assess and manage calls more efficiently than a clinician in an Ambulance. Correctly directing non-emergency demand away from emergency-trained clinicians will lead to less conveyances in the name of conservative medicine, and free up ambulances to deal with true emergencies.
  • The establishing of a separate urgent care service which can draw on the great work done by Ambulance Clinicians in the urgent care field, and the advantages of mobile assessment, and can progress in delivering the right care with improved training, equipment and GP support, without impacting the safe delivery of emergency care. This service can bridge the gap between emergency and primary care, taking the pressure off A&E.
  • The adequate funding of alternative, community pathways to take the pressure off A&E.
  • The introduction of a ‘Just Culture’ within the Ambulance Service to enable Ambulance Clinicians to feel able to give the correct care for the patient, not the correct care to keep their job safe.

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.