It is becoming increasingly evident that the desperate pursuit of government set targets has led to a misguided culture of subterfuge and misdirection within the ambulance 999 system. Under-resourced Ambulance Trusts so pressured to achieve impossible targets may be resorting to massaging the system to meet demands set by the government.
Beyond the simple failure to provide appropriate ambulance responses, of great concern is the alleged practice of inappropriate call categorisation. Rather than admit that Ambulance Trust’s inability to meet current demand, there is evidence to suggest that 999 call-handlers and clinicians in despatch are being encouraged to find ways to downgrade potential Red 1 calls that cannot be attended in 8 minutes. It has also been suggested that single responders in Rapid Response Vehicles are being reclassified as vehicles capable of transporting a patient in order to avoid sending an ambulance. If those practices are taking place, that undermines the already questionable validity of the present target-driven system of monitoring Ambulance Trust effectiveness. If dispatch staff are under pressure from a sinister culture of prioritising targets over genuine patient care, this is unacceptable and they need to speak out.
If these practices are evident to front line staff or from patient experience, this needs to be made known too. The culture in HEOC may be too pervasive to draw out concerned call-handlers and dispatchers without front line support. Concerned staff need to stand together and stand up.
Listen to your conscience. Everyone who works for the ambulance service is there for the same reasons – you are the kind of people who want to play your part in helping those in need, yet increasingly you are made to dance to the soulless tune of the ORCON piper. If things are going wrong, silence is not the solution.
It is important that staff understand that they have a legal right to raise concerns about such practices and are protected under the Public Interest Disclosure Act 1998. Below is important information covering how to “whistleblow” and additional links to Care Quality Commission are available in the sidebar to the right.
It is also important to recognise that this should not be viewed as an attempt to instigate a witch hunt against any individuals, but to highlight that the accepted culture of target-chasing has led to inappropriate working practices. It makes no sense to pretend that targets are being achieved if they are not. The ridiculous logic behind providing financial incentives to achieve targets has poisoned the noble goals of providing effective ambulance care. Road staff should not be forced to apologise for poor performance at every attendance and dispatchers and call-handlers should not be made mislead or coerce callers.
If this culture exists, it needs to be exposed and ended. As healthcare professionals and decent human beings, we have a duty of care to see that right is done. It is responsible governance.
Care Quality Commission
The Care Quality Commission is the regulatory body which is tasked with ensuring that healthcare services meet government standards. Part of the problem is that the exclusive pursuit of these government standards may be the root cause of the negative processes currently in place, but we need to operate within the systems provided to raise the alarm. With enough evidence, the CQC would be compelled to act. In their words:
“The Care Quality Commission is the regulator of healthcare, adult social care and dental care services in England. We register providers in accordance with the Health and Social Care Act 2008. We then inspect them regularly to check that they are meeting essential standards of quality and safety required by law, and take action against them if they are not. If the provider does not do what we ask and we believe people are at unacceptable risk of poor care, we have a range of strong enforcement powers.”
Frustratingly, their focus seems to be exclusively on the quality and safety of “patients and people being treated”, with little reference to the welfare of the staff themselves. However, as was discussed in the Broken Paramedic article “Why the Public Should Care About the Institutionalised Abuse of Ambulance Workers”, they are closely linked.
On the subject of staff fitness, CQC employer guidelines state the following:
“The law uses the word ‘fit’ in relation to staff and workers to mean two things. Firstly, it can mean the person is physically and mentally well enough to perform their role. Secondly, it can mean that the person is of good character, as they are honest, reliable and trustworthy, and that they have the right skills, qualifications and experience to perform their role.”
Under these guidelines, staff fatigue and the relentless physical and emotional pressures on a workforce stretched too thin could make a strong case in proving that patient care is suffering. Furthermore, the dilution of clinical skills with the introduction of the ECA role is evidence of attendances being made by staff without “the right skills, qualifications and experience”. I mean this as no disrespect to ECAs, they are being forced to provide clinical care without vital training simply as a cost-saving exercise.
Staff fears and misunderstandings about whistleblowing are covered in the CQC document Whistleblowing Guidance for Employees of Registered Care Providers, and I thoroughly recommend you read it.
“Whistleblowing is the term used when someone who works in or for an organisation raises a concern about malpractice, risk (for example to patient safety), wrongdoing or illegality. The individual is usually raising the concern because it is in the public interest: that is, it affects others, the general public or the organisation itself.
The Public Interest Disclosure Act (PIDA) protects workers by providing a remedy for individuals who suffer workplace reprisal for raising a genuine concern, whether it is a concern about patient safety, the essential standards of quality and safety set down by the law, financial malpractice, danger or illegality.
You might consider raising a concern with CQC where you do not feel confident that the management within your organisation will deal with your concern properly, or where you have raised the concern already but there is still a problem that the provider has not resolved.”
Emphasis mine. It is critical to remember that staff discontent, union pressure and media coverage is ongoing and gaining pace. In accordance with CQC guidelines, Ambulance Trusts have had ample warning and opportunity to address concerns but have instead chosen to apply more pressure to their staff and continue to support the existing broken culture of arbitrary target pursuit. I have personally spoken to the chief executive of EEAST and he is fixed on pushing through the existing proposals and building on this broken system.
If the staff of Ambulance Trusts all register their concerns with one voice to declare that things are going horrendously wrong, the CQC will have no choice but to investigate. We must then hope this will lead to those in power being properly informed of the travesties that are taking place daily. We cannot let the Ambulance Service continue to hide its failings.
I have already contacted the CQC, but although I am still an HPC-registered paramedic, as a former EEAST employee I am only considered to be a concerned member of public. They told me that any information I give them will not protect my sources under the Public Interest Disclosure Act 1998. The majority of the comments left on this site are anonymous anyway, but even so, my influence is limited as the CQC requires specific and current information in order to justify an investigation. This information needs to come from the staff themselves as the Trust are unlikely to release damning information willingly, which is why it is imperative that staff speak up. Even those in senior positions should have the conscience to realise that it is the right thing to do.
Ultimately, if it can be proven that the single-minded pursuit of questionable government targets is leading to inappropriate working practices, it will be the government itself which is responsible for bullying Ambulance Trusts into failing the public. There is no sense in blaming staff at any level. It is a change of direction that is required, not a change of personnel.
A Personal Note
As I have embarked on my attempt to raise concerns about the struggles of the ambulance service, I have fallen down a rabbit hole filled with stories of exhausted and frustrated crews and failing patient care. The further I progress, the more apparent it becomes how desperate the situation really is. You only need to read the many comments elsewhere on this blog, read the newspapers or search the internet to find many examples of how frequently and how badly the ambulance service is failing the public and its own workforce.
I am doing everything in my power to push for a change to rectify these problems, but alone my power is limited. As a blogging paramedic with 12 years of front line experience, I have some sway, but that alone will not be enough to make a difference. Not on my own.
In writing this blog, being published in the Mail on Sunday and very soon in the Eastern Daily Press, I am doing what I can to raise awareness and apply pressure. I have written to Norman Lamb, Minister of State at the Department of Health and MP for North Norfolk. I have attended a Trust Board meeting in an attempt to highlight my concerns to the EEAST chief executive Hayden Newton. I will continue to do what I can to bring effective change to our failing ambulance services, but others need to join the fight. I need to believe that others will push too, I cannot do this alone.
Road staff, dispatchers, managers, directors and unions all need to make a stand. There cannot be an individual among you that thinks things are going well. As the establishment flogs its staff in the desperate pursuit of meeting arbitrary targets, all sense of what the Ambulance Service should stand for has been lost. Instead of an effective support network of staff spearheaded by enthusiastic clinicians, the ambulance service has become a meat-grinder that sacrifices patient care and staff welfare in order to make the numbers fit.
The Ambulance Service is badly broken, this is your chance to fix it.
Further Information: A Powerpoint presentation covering Whistleblowing in the NHS.
Anonymous · 05/10/2012 at 19:00
Brave words Matt….and I admire everything you are trying to achieve but you are in rather a more comfortable position than the rest of us when it comes to whistle-blowing. It would be a very brave man or woman that stands up and starts rocking the boat whist still employed by the target at which his/her bullets are aimed….especially when like me they have a mortgage to pay and a family to feed.
Mat Westhorpe · 05/10/2012 at 19:42
But that's the point – there shouldn't be anything to fear. NHS whistleblowers are protected by law and by the fact that they have the moral high ground and a duty of care to uphold the interests of the public. The world is watching, so any employer who would move against someone acting in the interests of the public would be crucified. So now is the time to speak out.
Read the CQC documents linked above, get some advice if you need to, speak to your union rep. Whatever you need to feel comfortable with it. But most importantly, speak with colleagues. If concerns are raised en masse, who can they point a finger at even if they would? And who is they? There is no bad guy here, unless somebody wants to step up to take the role, which I doubt they do.
By definition, technically I can't whistleblow because I'm no longer employed by EEAST, but I would if I could. I'm just playing with the cards I've been dealt and doing everything I can to get wheels turning.
Anonymous · 05/10/2012 at 19:49
I take your point mate but you were where I am now. What whistles did you blow then.. ? I love what you're doing Matt. Don't get me wrong. Keep doing it. I will try to help.
Mat Westhorpe · 05/10/2012 at 20:00
I totally understand where you are coming from. I was in your position and I just did what I could to get through the day – by the time my shift was over I just wanted to get home and not think about it any more. At the time I had all the frustration, but not the direction to do something purposeful with it – I couldn't see the wood for the trees.
That's not to say I didn't butt heads with team leaders or send strongly worded memos to various members of management, but I didn't know about the CQC then and, like most staff, was convinced speaking out would end badly. Now I've had the benefit of time to reflect and do the research, I believe I've found a way to work within the system to make positive changes. Ironically, not being in the system any more means personally I have to find other avenues.
One of those avenues is trying to inform my former colleagues so they're not as impotent as I was and to empower them to do the right thing.
But I completely understand if it is seen as a risk not worth taking.
Anonymous · 06/10/2012 at 00:58
I have whistleblown anonymously to the CQC.
Yes I was very nervous when making the phone call (tel number on CQC website). I blocked my phone number and didn't give my name (they give you a reference number for follow up).
Their rules allow you to whistleblow anonymously because of previous cases such as the Staffordshire Hospitals scandal when some clinical staff were criticised afterwards for not whistleblowing because reporting poor care and corruption is a duty under your professional registration. I think it was accepted afterwards that this was a bit idealistic and it was likely to have an effect on your career if you whistleblow openly.
No I don't know if my limited information will do any good but I know if enough people contact them they will have to take it seriously.
Why did I whistleblow? After many years of loving the job I cannot accept the appalling care that EEAS is now providing to patients. I am genuinely concerned that if a member of my family was seriously ill or injured that they would not receive an appropriate and timely ambulance response. I am regularly receiving complaints from people including other emergency services waiting hours for an ambulance, some of the patients waiting are very unwell and exposed to the elements.
Most cat A calls over 8 mins away are downgraded by clinical triage, yes I accept some for genuine clinical reasons but most because they are more than 8 mins away. Its funny if a call is less than 8 mins away it rarely gets downgraded. Its a perverse fact that if you are critical, but more than 8 mins away then your call is more likely to be downgraded and you will not get the appropriate response.
Why the hell do we wait for a car to get to a cat A patient and assess them before sending an ambulance? As well as providing appropriate care I thought we had to achieve the 19 mins backup response or at least we were supposed to transport the patient? Now, reading comments on this website, it appears they are classing the car as an ambulance and achieving the 8 mins and 19 mins response with the car. Are we supposed to transport critical patients in the car? Sending a car to some patients (stroke patients for instance) is about as useful as the fire service sending a car to a house fire and reporting they have achieved the response time.
With all these cars, but not enough ambulances, the response paramedics end up waiting hours for backup (but at least they achieved the 8 and 19 mins response eh). What about patients lying in the street and RTC's, yes send a car by all means if it is the nearest resource, but send an ambulance as well because the patient is exposed to the elements and it can be very difficult to assess the patient in a public place or at night and in the rain, apart from the fact they may be unwell.
Yes I know, not enough ambulances, but covering it up and fiddling the figures isn't going to resolve it. Someone must be accountable and there is far more wrong than I can write about here but keeping quiet and hoping things will get better hasn't worked so far. With the plans for less ambulances… (sorry I mean the plans to "work smarter and match resources with demand") things can only get worse.
If enough of us express our concerns and the CQC do not investigate then when the shit finally hits the fan the CQC will have questions of accountability to answer.
Don't wait for it to be a member of your family.
Anonymous · 06/10/2012 at 10:25
Bravo Mr Anon! Now that the news is out that people can complain (whistle blow) without leaving a name then the door is open for everyone to follow suite. The first brick has been laid. Come on ambulance people stand up and be counted and a tower block will follow.
Anonymous · 07/10/2012 at 20:05
Does anyone know if all ambulance trusts are performing the same way? Do the response regulations allow them to count the car as a fully crewed and equipped ambulance capable of transporting cat A patients and allowable for the 19 minute response, or are they just stretching the regulations to impossible truths?
Whatever the answer, if this is actually occurring it is unethical behaviour and makes the 19 minute backup standard a pointless exercise to the detriment of the patient.
Anonymous · 07/10/2012 at 22:15
"Transforming NHS Ambulance Services" (2011) states "a vehicle able to transport the patient in a clinically safe manner, if required, to attend within 19 minutes in 95 per cent of cases".
So that excludes a car for a cat 'A' patient then.
Anonymous · 07/10/2012 at 23:16
I see EEAS are so short of ambulances they are using furniture vans to convey patients! (Daily Mirror).
Wonder if that is classed as a "clinically safe manner"
According to an ambulance spokesperson “Crews often commandeer vehicles to help transport patients to awaiting helicopters”!
All we need is to order a fleet of furniture vans and helicopters, problem solved.
Mr Smith · 08/10/2012 at 11:33
Within the NHS there are people that earn lots of money for doing very little and lots of people that earn little for doing lots of work. The savings/austerity measures will be implemented by this government whatever the protests so the argument is about where those cuts should be made. Unfortunately the people that make these decisions i.e. the MP's are more likely to be in cohorts with the high earners than the lower paid i.e. the ambulance workers,nurses etc. Therefore any campaign to change the areas in which the cuts are made will need to be a very compelling argument indeed. I wish you and your wonderful colleagues good luck with your fight.
Anonymous · 08/10/2012 at 14:04
I heard that the patient transported in the furniture van because of the lack of ambulances had a lucky escape.
The next vehicle that came along was a hearse!
After discussing it the doctor and paramedic decided they couldn't "commandeer" that because they would have had to leave the deceased at the side of the road while they transport the patient!
"Some mothers do ave em" indeed.
Anonymous · 08/10/2012 at 15:09
Talking to other paras there have been a number of occasions when helicopters and RRV's have been delayed on scene for hours waiting for ambulances, either because they require a spinal board to extricate a patient, there is more than one patient or they cannot transport the patient in the helicopter.
Apart from the 'Golden Hour' implications for the patient, what a great use of a charity resource wasting all that time and very often leaving roads blocked for hours.
We can respond helicopters but not a frigging ambulance. When they do respond they are often given the call as a 'green call'.
Anonymous · 08/10/2012 at 22:14
and lets not forget the infamous A.E.D that if on scene stops the clock.
can it stop bleeding? no
can it administer drugs? no
can it clear an airway? no
it has only one purpose and thats a rare event.
but it somehow turns into a first responder, based twenty miles away that got to the job in a second and a half to make sure orcon was hit !!!
Willie Watford · 22/10/2012 at 21:45
Paras, techs,saps and eca's ……..now is the time. You must act to stop these pen-pushing plebs from destroying the ambulance service and ultimately destroying YOU. You are wounded, demoralised,down-trodden but you are far from defeated. There are ways and means to fight back. You must act in every way possible before it is too late. You are intelligent people. Use that intelligence to hit back. Don't leave it to someone else. ACT NOW !!! Blow those whistles and blow them loud. Mat Westhorpe is leading you to the water. HE CAN'T MAKE YOU DRINK IT. That is something…..as hard as it might seem, that you have to do yourself. DO IT TODAY for a better service for everyone.
Anonymous · 23/10/2012 at 13:09
Unfortunately, this problem is nationwide now, so it will take a lot of effort and willpower to stop it before the 'services' can no longer cope.
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