“DESPACHO SECRETO” O SEGUNDO

Ambulance services across the UK are faced with multiple challenges imposed by different stakeholders. Not only that, but also the need to focus on a set of strategic priorities, in addition to coping with the increased demand on the service and funding issues, as well as complying with the national standards and targets, clinical care, patient safety and education, workforce, and development (Association of Ambulance Chief Executives,2016). The demand on the ten English NHS ambu-lance trusts in England continued to grow in 2015/16. It has increased more than 15% over three years, resulting in almost 30,000 calls a day (Association of Ambu-lance Chief Executives, 2016). Ambulance trusts are moving towards applying new operating models which are clinically based, in order to alleviate ED attendances.

For instance, managing incidents through increasing the rate of ‘Hear and Treat’

(Section 1.1explains different pathways) services from 5.9% in 2013/14 to 10.2% in 2015/16 (Association of Ambulance Chief Executives, 2016).

NEAS, among other ambulance services in the England, prefers not to convey a patient to ED unnecessarily, especially where there is no urgent life threatening medical need. Conveying patients to ED unnecessarily poses financial and time burdens to the ambulance services. It also adds more pressure to ED and services provided to patients. That is why treating patients on scene by qualified ambulance crew then discharging them can alleviate the pressure on ED attendances, hospital admissions and conveyance by ambulance services (The House of Commons, 2013).

In December 2016, of all 999 calls received to NEAS, 35% were seen by an ambulance crew but not conveyed to ED. On the other hand, 21,364 journeys to ED were made during the same period of time (The Association of Ambulance Chief Executives, 2017).

NEAS is the authority responsible for providing emergency medical service to the population in the North East of England. It is critical when analysing financial costs and performance in ambulance services to be accurate in the matter of distinguishing

various courses of action, meaning defining the immediate expenditure of various pathways that can be delivered to the patient in need. For instance, differentiating the immediate costs of calls (when a call handler applies ‘Hear and Treat’ then discharge), the cost of call-outs (dispatching an ambulance vehicle to an incident and providing care on scene), and the cost of conveyance (when the ambulance crew conveys patients to ED or any other pathway). Data highlighting the expenditure of those different pathways in different time periods, are scant in the literature and government reports. Studies and reports identified in the following paragraphs, are concerned with the impact of time and immediate expenditure. This is merely to accentuate the importance of identifying immediate expenditure and the impact of time with drawing no relation between the two. Also, it is important to note that the study presented here, in the following paragraph, is focused on people aged 65 who had fallen and required assistance or were conveyed to ED. This is to illustrate the immediate costs of different pathways of NEAS.

In 2004, a seven month study period in Newcastle upon Tyne, UK on the el-derly population, over the age of 65, was conducted by Newton et al. (2006), which revealed the costs of falls in the community to NEAS. Their study highlighted some interesting results. The cost of a call-out for NEAS was £115. This cost is not the same if the crew were to spend time on scene with the patient for assistance or treatment, the cost in this case would be £123 per hour of crew time spent on scene.

The time spent on scene with the faller to be assisted or treated on the spot was significantly longer compared to the time spent on scene for those being conveyed to ED. This resulted in the cost for assistance or treatment on scene being greater,

£173.16 per call-out, compared to the cost of conveyance to ED which is £142.40 per call-out. Table 2.1 tabulates this information clearly.

Call-out Status Cost Unit

Call-out only £115 per call-out

Call-out only £123 per hour

Call-out with treatment/assistance on site £173.16 per call-out Call-out then conveyance to ED £142.40 per call-out

Table 2.1: Cost of Call-outs in NEAS, 2004

Presenting the immediate cost published by The National Audit Office for the North East region of England can give an idea of expenditure fluctuation, however, they do not present the different expenditure for the various pathways that can be delivered to the patient in need. Table 2.2 tabulates the information clearly. For

Financial Year Immediate Cost of a Call-out

2007-2008 £171

2008-2009 £180

2009-2010 £176

2015-2016 £235

Table 2.2: Call-outs Expenditure Fluctuation for the North East of England

the year 2007-2008 the cost of a call-out, in the general population, was £171. For year 2008-2009 this was £180, and it was £176 the following year 2009-2010 (The National Audit Office,2011). Further, for the year 2015-16 the cost per call-out was

£235 (National Audit Office (NAO),2017).

Regarding the time impact, the average time spent on scene in 2015-16 in the region NEAS covers was 26 minutes 49 seconds, and the average travelling time to a hospital for the same period was 16 minutes 20 seconds (North East Ambulance Service NHS Foundation Trust (NEAS), 2016a). In 2015 alone, NEAS received 575,133 calls. Of those, 377,608 calls required an ambulance dispatch, and 295,008 resulted in the patient being conveyed to ED (North East Ambulance Service NHS Foundation Trust (NEAS), 2016b). For the group of interest in this thesis, from April 2012 until August 2015, 2483 cases with fits were seen and treated on site, while 6127 cases with fits were taken to ED, so that 0.63% of cases with fits were taken to ED (North East Ambulance Service NHS Foundation Trust (NEAS), 2015b).

Tian et al.(2012) observe that 9.5% of emergency admissions in England 2009/10 for Ambulatory Care-Sensitive Conditions (ACSC), were for convulsions and epilepsy, placing this as the fifth leading cause of ED admissions. ACSC are those chronic conditions that can be managed by primary and preventive care centres in order to

avoid unnecessarily admissions to hospitals and ED (Purdy et al.,2011;Tian et al., 2012;Purdy et al., 2010).

A study conducted byDickson et al.(2016) revealed that 3.3% of all emergency incidents for the Yorkshire Ambulance Services (YAS) were incidents of suspected seizures, for which 97% had an emergency vehicle dispatched and 75% of those were taken to hospital. The annual estimated cost of the emergency management of suspected seizures in the English ambulance services is £45.2 million.

Faced with cases of seizures, paramedics find it clinically safer to take patients to ED, due to the lack of guidance, care pathways, lack of experience, anxiety over litigation, and lack of access to patients’ medical information (Zorab et al., 2015).

Hart and Shorvon(1995) in their study which included only PWE who were receiving treatment for the condition, revealed that the most common reasons for 43% of them to visit the ED were due to an occurrence of an uncomplicated seizure with either clusters of seizures or due to prolonged seizures, or an injury caused by a seizure.

Their study suggests providing recommendations regarding care of PWE and their lack of hospital follow ups, direct referral to a consultant neurologist or a specialist epilepsy clinic, and PWE notes that lack information regarding their condition.

What has been highlighted are some of the factors influencing the constant pressure imposed on the ambulance service trusts in England regarding PWE, and how seeking to tackle some of those factors will help ambulance trusts to concentrate on real genuine emergency incidents.

2.4.1 User Perspectives on the Ambulance Service

Ridsdale et al. (2012) in their qualitative study reported PWE’s explanations for using the emergency services. PWE did not use the emergency services solely because of a seizure occurrence, as other triggers were associated with this action.

The lack of available family members, or of a knowledgeable significant other person, the public’s shock when faced with seizures, and fear of sudden unexpected death

were reasons identified for using the service. Furthermore, carers would often call the emergency service if they noticed something unusual about the PWE, or if they were uncertain about what actions to carry out (Ridsdale et al., 2012).

There are other factors affecting user’s perspectives and their actual needs from the ambulance services. For instance, PWE who experience a seizure do not want to be taken to ED unnecessary by the ambulance, especially if they are undergoing an un-deviated seizure episode of their normal pattern and if they are in the company of someone who is sufficiently informed and confident to support and manage the situation (Ridsdale et al., 2012). In addition, carers would like to be assured that transportation by the crew to the ED will only occur if there is a genuine need for help. The ambulance crew would like to have more information regarding the patient, that would help them assess the patient and support their decision-making while on scene, in order to select the pathway appropriate to the condition and situation (Dickson et al., 2016).

Burrell et al. (2012); Ridsdale et al. (2012) conducted a study regarding on scene decision-making by paramedics when needing to care for patients with epilepsy.

Paramedics expressed their desire to have ready access to information about previous seizures in addition to related patient health information. Some expressed the lack of adequate organizational support in the case of litigation, encouraging them to decide to take the patient to ED as a safety net. They also reported insufficient guidance, practice and training when it comes to dealing with PWE on scene.