Health: Don't dial that number

The ambulance service is under increasing stress, exacerbated by people misusing the 999 call-out as little more than a quick and free taxi-ride to hospital. If standards are to be maintained, something will have to change.
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Big white taxis. That's the name sometimes used, only half in jest, by emergency personnel to describe an ambulance. Because, some of the time, that is how patients see them - as a free ride to hospital. An entitlement. Something they pay their National Insurance for.

The Audit Commission, in their report A Life in the Fast Lane, have attempted to tackle some of the issues surrounding the pounds 470m that emergency ambulances cost the NHS each year, and the frank abuse of the service that costs us all dearly. It is a stark fact of life that, if an ambulance is summoned to someone with a bruised thumb, it means one less ambulance available to attend to your grandmother's heart attack.

Anyone who dials "999" at the moment in this country is likely to be sent a fully-equipped ambulance, plus a crew of two personnel, one or both of whom will be highly and expensively trained paramedics. The average cost of an emergency ambulance call-out is estimated at around pounds 100. But try explaining to a patient, once he or she has arrived at hospital, that their use of the "999" call was inappropriate, and more often than not you are met with a blank stare - or open hostility, followed by the inevitable: "So how are you going to get me home, then?"

The term "inappropriate" can be illustrated by the following examples: sore knees for 36 years, feeling seasick after getting off a Thames pleasure cruise, itching under the top of a plaster of Paris leg cast, and a speck of dust in the eye. All these people dialled three nines.

The situation is further complicated by those patients who do indeed need to come to hospital fairly urgently. They just don't need to arrive in a blaze of flashing blue lights. Many of these are Doctors' Urgents: ambulances requested by family doctors to take patients from their homes to a pre-arranged hospital bed. Doctors' Urgents are, for some reason, less urgent than other people's urgents, and have to wait a little longer. So families sometimes resort to dialling "999" in an attempt to jump the queue.

By 2001, patients whose lives are at risk are expected to get an ambulance within eight minutes, according to government targets. With emergency calls to ambulance services increasing by 5 per cent every year, this target will be impossible to achieve unless something changes radically. There are two ways of accomplishing this. Either change the demands made on the service, or change the service itself.

Three main methods are suggested to lighten the burden. Treat some patients at home, without moving them to hospital; lengthen the response time for less serious calls; send a vehicle and crew commensurate with the severity of the patient's condition.

In most NHS trusts, even paramedics, who have the same skills as doctors in the resuscitation of the critically ill, are not empowered to make a decision if someone does not need to be taken to hospital. While they are legally entitled, they are culturally forbidden. All it takes is one error of judgement to ruin an entire career.

The other two options both rely on good communication, something that is very difficult in even the most dubious emergency. The corporal, as the apocryphal tale goes, dispatched the following message from the front: "Send reinforcements. We're going to advance." What the general received was "Send three-and-fourpence, we're going to a dance." The same sorts of thing happen when someone at ambulance control (effectively a telephonist, in most cases) is trying to find out from a patient exactly what his or her condition is, and then relay that message to an ambulance crew.

"Eighteen-year-old cardiac arrest. Shot three times," had one casualty department on full standby with a team of cardiothoracic surgeons. What arrived was a man of 80 whose heart had stopped and who had received three electric shocks in an attempt to restart it. An emergency, certainly, but one with a rather different flavour to that of a gunshot injury.

Easing response times, or sending different types of responders to different patients, both require the practice of something frowned upon by many: prioritisation. Someone has to decide the significance of the symptoms described over the telephone, without seeing the patient. Whether the right thing to do is to place the call further down the queue, or to send a one-man motorbike rather than a two-man wagon, the decision is basically the same, and it's always difficult to get right. Which is why some services, such as that in Staffordshire, have decided to concentrate on getting an ambulance to every shout as quickly as possible, rather than attempt to prioritise. They put some of their crews on "standby" on street corners, from where they can reach patients quickly, rather than at the ambulance station. This is a luxury other services, such as those in inner city areas, would kill for.

Those services answer hundreds more requests for assistance, in places with average traffic speeds of eight miles per hour, where a proportion of the population does not have English as a first language, and where many people are not even registered with a GP. With so many differing needs, one thing we do not need is a nationally uniform system.

Another approach is to try and "influence demand directly", in other words to dissuade people from calling an ambulance when it is not necessary. Such campaigns have met with little success in the past, and there is the ever-present spectre of risk that the genuinely ill may be deterred from making that vital call. The pilot scheme for "NHS Direct", planned as a national local-rate telephone health advice line, has just been extended, and it is hoped that services like these may eventually lessen the number of emergency calls made.

Some are sceptical about the ultimate effectiveness of NHS Direct, for two main reasons. By the very nature of telephone advice, it is inevitable that most conversations will end with, "But if you're still worried, you should see a doctor", and some people will interpret this as meaning an emergency call.

Whatever is done to solve this problem, it is going to involve as much in the way of attitude changes as in logistical changes. Patients must distinguish the ambulance service from taxis and advice lines, and the service must learn to put the considerable skills of its staff to better use.