When is an emergency not an emergency? What is an emergency?
‘999—Fire, Police or Ambulance? How can we help?’ The familiar phrase we used to hear when we dialled the British emergency services number used to be a reassuring opening to the call and at the same time alerted us to identify whichever service was needed, ensuring that not a moment was lost. However, in 2022 things have changed as we find ourselves launched into a Brave New Health World.
The Ambulance Service in the UK is on its knees. There are threats of a complete cessation of dispatching ambulances in response to 999 calls in some areas by August. We are told the immediate cause is overwhelmed ambulance crews, with more acutely sick people requiring the most urgent ‘blue light’ ambulance dispatch. Mark Docherty of West Midlands Ambulance Trust warns of a ‘Titanic moment’, with the tipping point being caused by full wards and there being nowhere left for his ambulance colleagues to deliver their patients to. Late spring is historically an unusual season for hospitals to be overcrowded. Winter has passed, as has the flu season, so where are all these patients coming from who require emergency care, and why now?
Queues of ambulances outside the admissions entrance are now a regular sight at Accident & Emergency departments in many of our hospitals. Reports of patients dying at the scene of illness or injury due to delays in attendance—and of others dying in ambulances, unable to get the urgent care they need within the hospital—are growing. Crews are constantly being kept off the road as they are obliged to become the main carers for their patients for hours at a time until they can safely hand them over to doctors and nurses within the hospital premises.
The UK Government has just earmarked £36.3 million to provide state-of-the-art new vehicles to add to the ambulance fleet. Paramedics will also be given body cameras to dissuade violence from the public. Patients will be encouraged to ‘sit if fit’, to relieve some of the pressure on ambulance spaces. In line with the NHS Long Term Plan, the Government intends to replace 90% of the fleet, switching to ultra-low and zero-emission vehicles by 2028. Staff will also be incentivised to use electric vehicles.
But is this the answer? As the UK gives away older models of ambulances to Ukraine, some may be forgiven for having their doubts, as charity begins at home. Perhaps the increasingly publicised generous donations of road ambulances and air ambulances by the Freemasons should be applauded, but is the fundamental problem really as simple as a shortage of vehicles and trained crews to man them—or is there more to it?
As we enter high summer, a season when we would normally expect to be able to catch up on waiting lists of patients currently needing elective surgery and treatment, we instead find our hospitals at bursting point, with acutely sick patients requiring intensive treatment. Why?
Half a million adults are now on social care waiting lists as they struggle to access vital services due to serious staff shortages in the care service. An increase of 72% just in the past year of those waiting for care assessment has brought the total backlog to 506,301. Currently, priority for social care is being given to those cases where abuse or neglect has been noted and to hospital discharges. According to a report published by the Association of Directors of Adult Social Services (ADASS), Waiting for Care, almost 170,000 hours a week of home care could not be delivered because of a shortage of care workers during the first three months of 2022. This was a sevenfold increase since spring 2021. The situation is continuing to deteriorate, with a growing number of people needing care with increasingly complex needs.
The NHS Long Term Plan 2019 maps out a vision for the future where everyone takes responsibility for their own health. Hospital at Home is the way forward. Virtual wards, remote monitoring, surveillance and biosensors will become the new normal. Yet ADASS challenges this model, pointing out that making hospitals the focus of resources without addressing care and support at home will mean that many deteriorate even more and end up needing hospital care after all.
As ambulance services collapse and disappear, what are the plans for the future? Will there even be a need for any ambulances? Will these be autonomous and manned by robots? The NHS Long Term Plan includes a fleet of ‘secure mental health vehicles’ with specially trained mental health crews to take patients to our new mental health hubs, which are currently being rolled out; but where will the standard ambulances be taking their occupants?
There are four prioritisation categories for British ambulance crews:
- Category 1 – Life-threatening – response time 7 minutes
- Category 2 – Emergency calls – response time 18 minutes (stroke patients will be sent a specialist stroke unit)
- Category 3 – Urgent calls – response time 120 minutes and you might be treated within your home
- Category 4 – Less urgent calls – response time 180 minutes (3 hours); callers may be given advice over the phone in lieu of an ambulance dispatch
This model is inherently questionable. Given the importance of the ‘golden hour’ to save lives in emergencies, why are patients suffering strokes relegated to Category 2?
Currently, patients can be left waiting for ambulances for up to twelve hours, only to be left in their ambulance outside a hospital for another twelve. Others are simply dying en route, or even before ambulances arrive. What has sparked the sudden epidemic of 999 calls? How many of those requiring the most urgent ‘blue light’ ambulance response have had a Covid-19 vaccine and are suffering a serious adverse reaction? Is anyone asking that within the system, or does anyone care? Cancer patients requiring ambulance transport to attend their treatment are either not arriving for their treatment or, if they do make it, are made to wait for anxious hours to be picked up and again to be returned home after gruelling treatment. This is quite clearly unacceptable and cruel.
The layers of problems continue to peel off as we look further. When is an NHS ambulance provider not actually the NHS? The NHS logo is used by many private companies, giving the illusion to the public that they are in the hands of trained NHS staff. This is not always the case, as ambulance services are outsourced nowadays. One of the United Kingdom’s biggest private ambulance services, Falck UK Ambulance Services, is repeatedly failing, and leading cancer specialist hospitals say that since the system was outsourced to Falck, it has become ‘chaos’. What a relief that the Freemasons are busy donating new vehicles; we must all be grateful, must we not?
Far from the gold standard emergency care that we are used to in Britain, there are many harrowing stories now emerging as a result of a broken system: shared ambulances during lockdowns, poorly trained staff and sloppy care. England’s North East Ambulance Service is now under investigation after whistleblowers raised concerns over the way in which the ambulance service has been dealing with coroners’ court cases. Have patient death records been altered or suppressed?
Clearly, there are many problems within our ambulance service; but what other factors are contributing to this meteoric rise of ‘incidents’, deaths, and unacceptable and long waits? That question surely has to be directed to those running our hospitals. Why are all the beds full? Why aren’t patients being discharged; are we facing a summer of bed-blocking ahead? Evidently, we are. Social care is on its knees as it struggles to find both care and carers to look after our most vulnerable and elderly, who simply have nowhere to go and no-one to look after them.
In the reporting year 2020–21, for England alone, the Ombudsman received 2,033 complaints and enquiries about adult social care. This included 270 remarks about independent care providers, the sector in which the client arranged and paid for his or her own care. As in all areas of its casework, last year the Ombudsman received and decided fewer complaints than in the previous year, because of the disruption caused by Covid.
Many care homes have been forced to close during and after the Covid-19 pandemic; but a fall in occupancy rates, and fewer people privately funding their care, is a combination that has led to some care homes receiving less income, with a constantly rising cost of living crisis. This would appear to follow a significant number of deaths of residents during the pandemic. Many are wishing now to remain at home rather than choosing the care home option. The Hospital at Home concept appears to have arrived without us even noticing the sea change. As new ways of delivering care at home using remote devices and biosensors mature, fewer patients need transporting to hospital.
Our National Health Service, Ambulance Service, and social care sector are broken. One will not work without the others, and until all three are working in synchrony, we must prepare for things to get far worse before they improve. Safety belts on; it’s going to be a bumpy ride in the ambulance.