The following Ambulance Service Network (ASN) article was published in the Health Service Journal in June 2008.
Next week Ara Darzi will publish the results of his NHS Review. Whilst the final details will no doubt be wrangled over this weekend, the direction of travel is clear. The NHS must take the leap from good in many places to world class in all in order to save more lives, improve health and tackle inequalities. Services must be specialised where necessary, and localised where possible, with the overall focus shifting more towards prevention.
The regional Darzi reviews that have already been published make transforming services for trauma, heart disease and stroke a top priority (see Regions braced for change as plans put Darzi's vision on map, HSJ, 19th June 2008). Some Strategic Health Authorities have been clearer than others in spelling out what this will mean in practice, for example specifying the number of specialist centres in their region. Although no one model of care will be right for the whole country, the evidence shows that early treatment for critically ill patients and those suffering from trauma saves lives and increases the chance of recovery, with better outcomes in specialist centres.
Ambulance services have a vital role to play in developing the right care pathways for these patients. No one goes to hospital to have a heart attack or a stroke: they have them at home, in their local neighbourhood or in the workplace. Ambulance services need to get to the patient and start treatment as quickly as possible, as well as taking them to the best place for their care. New types of staff - including specialist paramedics called Critical Care Practitioners who have advanced resuscitation skills and can provide a wider range of pain reliving drugs - can help take seriously ill patients to the place where they will have the best chance of survival, even if this is further away.
Many parts of the NHS understand how the ambulance service can help 'add years to life' by improving emergency care. There is much less awareness, however, about the ambulance service's role in 'adding life to years' by improving other types of services.
The ambulance service isn't just the 'blue light' emergency service seen in TV programmes like 'Casualty': it is also one the most important gateways into the health and social care system. 7.2 million urgent and emergency calls were made last year and 5.9 million of these calls were attended by ambulance services. Around 1 in 10 patients seen by the ambulance service are critically ill or suffering from major trauma. The vast majority have non-life threatening conditions. Many are older people who have had a fall, patients who have exacerbated mental health problems or other chronic conditions, and people with minor illnesses and injuries. It is this latter group - those with urgent rather than life threatening conditions - that is driving the increase in demand for ambulance services, by on average five to seven percent each year.
Instead of criticising patients for making 'inappropriate' use of ambulance services, we need to better understand why people are calling 999 and use this information to ensure the right mix of care is available, in the right place, at the right time.
Ambulance services are already improving their ability to assess and diagnose patients, so they get the best care for their needs rather than always sending a frontline ambulance. Ambulance services are also delivering more care for patients in the local community so they don't have to go into hospital unnecessarily, for example running minor injuries units and using emergency care practitioners to assess, diagnose and treat minor illnesses in patients' homes.
But more radical changes are needed if we are going to genuinely transform urgent or 'unscheduled' care. The first and most important step is to develop a single point of access for urgent and emergency care so that all patients are assessed and prioritised in the same way whichever number they call: 999, NHS Direct or out-of-hours. The single point of access should be co-ordinated regionally and linked to the appropriate service response. This would require a directory of services with real time information showing where urgent as well as emergency services are available near to the patient, including walk in and urgent care centres, GPs (in and out of hours), district and other community nursing, mental health crisis intervention teams and social care services. This model is already being developed in the North East through a new system called NHS Pathways.
A new, easily remembered national telephone number for urgent care - perhaps '888' or '247' - to sit alongside 999, should be piloted to assess the potential to further simplify access for patients and improve the co-ordination of care.
A single point of access, supported by a local directory of services, would in turn help identify where patients health and social care needs aren't being met. Primary care and practice based commissioners could then use this information to develop a range of primary, community and other urgent care services available 24 hours a day, seven days a week.
This model of care could play a major role in tackling health inequalities. Recent research shows that ambulances are four times more likely to be called out to deprived areas than to affluent ones, and poor access to primary and community care is likely to be a crucial factor.
It could also help deliver more cost-effective care. Around 70 per cent of incidents attended by the ambulance service result in a patient being taken elsewhere to continue their treatment, usually to hospital. Whilst this figure fell slightly in 2007/08, there were still 4.26 million 'patient journeys'. The cost of sending an ambulance to someone who calls 999 is around £200. The total cost to the NHS will be far greater if patients are then taken to Accident and Emergency and admitted into hospital overnight or for longer.
Delivering the best care for patients, and the best value for money for taxpayers, will require important changes to the way urgent and emergency services are measured and funded. Ambulance services should be assessed according to patients' outcomes and experiences, as well as response times. Outcome measures could be specific to conditions, for examples assessing the percentage of stroke patients fast-tracked to specialist services for CT scanning within 3 hours of their symptoms starting, or the percentage of patients with a long term condition who are treated by paramedics out of hospital, or referred to another appropriate community services.
Shifting the focus to outcomes means ending the practice of keeping data within individual providers - for example hospitals or mental health services keeping their data, ambulance services keeping ambulance service data - so that data is shared across the health and social care system.
We also need a system of funding for urgent and emergency care which incentivises services to give patients the most appropriate care, in the most appropriate place, rather than resorting to taking them to the closest A&E.
Changing cultures and attitudes will be as important as changes to the 'system'. In the past ambulance services have been seen as having greater links to the other emergency services - the police and fire service - rather than to the rest of the NHS. And ambulance services haven't always engaged as well as they should with their managerial and clinical colleagues. These attitudes are changing, but more needs to be done to improve understanding and communication on both sides. It is only by working together that we will transform the outcomes and experiences of all the patients we serve.
Joining the Ambulance Service Network
I was a Special Adviser to Patricia Hewitt when she was Secretary of State for Health. It was a great job and a real privilege to work with so many talented and committed people, and I learnt a huge amount.
Politicians have a vital role to play in ensuring the NHS gets the investment it needs, that the right national frameworks and incentives are place, for example on regulation, and to pass legislation where it can help improve health, such as the smoking ban.
But many of the changes that are needed to improve the NHS are in the hands of staff themselves. I joined the Ambulance Service Network because I want to be part of making that change happen on the ground. Many of the biggest challenges the NHS faces can only be addressed if ambulance services are involved, whether that's transforming stroke or trauma services, improving care for older people and those with chronic physical and mental health conditions, or tackling the big public health problems like alcohol. The ASN was established as part of the NHS Confederation to help make this happen.
