Bringing healthcare to the patient?

In June 2005 the Department of Health launched their report on a strategic review of UK ambulance services at the annual ‘Ambex' conference. The report is titled Taking healthcare to the patient, but perhaps its subtitle “Transforming ambulance services” more accurately indicates its content.¹ Its recommendations will result in the most profound change for ambulance services since the introduction of the national paramedic programme in 1990, and arguably the impact will be considerably greater.

The report's proposals explicitly recognise the necessity for ambulance trusts to address the needs of the majority of the users of 999 services, who have neither life threatening or time critical emergencies. Over a decade ago it was reported that as many as 50% of 999 patients transported to emergency departments were discharged without significant treatment or referral,² suggesting that they could have been managed outside the hospital system.

Taking healthcare to the patient makes 70 recommendations. These address key areas that include improving the speed and quality of 999 call‐handling, providing more clinical advice to callers, and improving integration and consistency with other call taking agencies handling out of hours requests for care. Ambulance trusts are also tasked with increasing the range of healthcare options provided to unscheduled users of the NHS, and with broadening the portfolio of services they offer including, for example, health promotion and diagnostics. Patients with true emergencies are not forgotten, and the recommendations aim to improve the speed and quality of response to this group.

Specific proposals include the development of a standardised competency and training framework for ambulance dispatchers, increasing the evidence base to improve the accuracy of 999 call triage, and an increase in the provision of clinical direction and quality control in dispatch centres. It is proposed that ambulance staff should work with General Practitioners (GPs) within and out of hours to undertake home visits (including routine diagnostic testing) and to see patients in surgeries, rotating through urgent care centres to develop their own practice and manage demand.

Ambulance services are also tasked with improving the management of major trauma, providing more effective pain management (especially for children), and improving the care provided to patients with cardiovascular disease (including stroke), in part by increasing direct admissions to specialist centres. Response time standards will become more challenging as the clock will start when a 999 call is connected—significantly earlier than is currently the case. Response standards for GP urgent calls will become the same as for 999 calls.

These are challenging objectives, and the paper recognises the need for support through management development initiatives and improved training for ambulance clinicians. In particular, a move from vocational training to higher education institutions is planned, with a foundation degree becoming the entry route to paramedic registration. A clinical career pathway option is also proposed, as is increased commonality with other health profession's education programmes.

Although all of these changes are very positive for the ambulance profession, each will require significant effort, and some are based on very tight deadlines. Operational performance must be improved dramatically to meet the new targets within a year, and ambulance training moved to universities by 2008.

The recommendations, however, come with a sting in the tail: ambulance service reconfiguration. A consultation paper is currently circulating that proposes merging the current 31 ambulance trusts into 11 new organisations, largely sharing boundaries with Government Regional Offices and the new Strategic Health Authorities.³ The Department of Health envisages a number of benefits from this regionalisation, including freeing up management costs to support clinical service provision, and a higher benchmark level for standards of service. Evidence suggests, however, that merged NHS organisations do not meet targets for management cost savings, and the small savings that are achieved may not be invested in patient services.⁴ Significantly, mergers have a negative effect on service delivery due to loss of management focus, and service developments are delayed by up to 18 months.⁴ It is a basic principle of strategic management that mergers of failing organisations do nothing to improve financial or operational performance—they just create larger failing organisations.⁵

The recommendations made in Taking Healthcare to the Patient are by themselves of sufficient magnitude to challenge even the most talented of NHS management teams, affecting the operational, clinical, and educational domains and mandating the development of new working relationships with a vast range of external organisations. Requiring that this is achieved in parallel with the management challenges and inevitable chaos of organisational mergers on a national scale risks catastrophic failures of the front‐line emergency service of the NHS.⁶