ࡱ>    !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijRoot EntryZ O2@[}=kCONTENTS CompObjVSPELLING(er to retain a position or receive Trust financial rewards. The Panel remain concerned that Ambulance Trusts provision of Air Ambulances is both costly, ineffective, and is being used for the sole purpose of attempting to upgrade response targets and is a misuse of Charitable and Public funds. The Panel strongly advise, that the Government must instigate an Independent Inquiry, into the whole structure of Ambulance Service Trusts, in order to re-establish, National standardised Vehicles, Equipment, and Training. This to include response targets, and a review, with reestablishment of the Ambulance Core duties and responsibilities, in order to provide an expected reduction of overall Ambulance Trust spending, coupled with improved realistic National standards of public expectation. Copies to John Reid Secretary of State For Health P. A. Littledyke Chairman British Ambulance Service (Foresight) Panel (BASP) Reprint from 7th September 2004 COULD IT GO BADLEY FOR BRADLEY A BASP REVIEW OF THE BRADLEY REPORT Lord Warner: Ambulance services consistently reach over 75% of immediately life-threatening (Category A) calls within 8 minutes a standard that bears worldwide comparison. In the week leading up to the publication of the report, this has been proved to not be the true picture Lord Warner:  the far greater number (of patients) who do not have a life threatening condition, but (who) are seeking urgent advice or treatment, and those who condition or location prevents them from travelling easily to access healthcare services. This has been brought about by the Governments actions of allowing G.Ps to opt out of the essential 24 hour care, this effect has left a very large and considerable gap within the Health Care system, which the Government hopes can be filCHNKWKS TEXTTEXTFDPPFDPPFDPPFDPPFDPCFDPCFDPCFDPCSTSHSTSHSTSHSTSH2SYIDSYIDPSGP SGP dINK INK hBTEPPLC l BTECPLC FONTFONT<STRSPLC :PRNTWNPR" FRAMFRAMTITLTITLR&DOP DOP x"esponse targets and is aBASP VIEW September 2004 BASP warned the Government that Ambulance Services were diversifying to an extent that will affect severely primary core duties, and that Ambulance Trusts were and will ,continue to 'Fiddle' response times unless action was taken at a early stage. The Panel remain concerned that the use of fast response vehicles has indeed become a dangerous practice. These vehicles are being sent to all categories of call at 'full response speed', not just those involved with Cardiac and acute breathing problems Cat A, In East Anglia Ambulance (EAA) in less than 3.3% of cases the response vehicle have been able to transport such cases, we believe these are cat C cases which do not require 'full response speed', when in 96.7% of the cases an ambulance has been required to transport, and this may have resulted in Two vehicles attending, increasing service wage costs by at least 33%, and double the possible accident risk to vehicles attending. EAA would like us to believe that this is the other way round and that Ambulances do not need to attend, only cars ? Likewise we have concerns that in many counties the car fleet amounts to some 50% of the service availability and that fully crewed Ambulances are becoming less available than response cars. This is affecting Doctors Calls for Ambulances as well as A & E duties The Panel remain concerned that Ambulance Trusts have not recorded correct times over a considerable period, and the true picture is under represented, the Government and others will never be able to solve the root problems whilst these figures continue to be misrepresented, fudged, or fiddled without due foundation. The Executives should be accountable in these cases and disciplined as in the past when found to misrepresent performance in ordled through promises that Paramedics can fill this gap. Lord Warner:  Over the next five years, ambulance services will provide a world-class system of call handling and telephone based clinical advice. This means that the new super Ambulance Trusts will be running and providing NHS Direct, thereby increasing the NHS Ambulance Trusts Budgets and staffing levels through expansion. Lord Warner:  They (Ambulance Services) will work as part of the primary care team to help provide diagnostic services and support for patients with long term conditions. The Ambulance Trusts will also expand through undertaking the  Out of Hours services within the community (the current Doctors out of hours arrangements that are not working effectively) Lord Warner:  The report also recommends reconfiguring and reducing the number of ambulance services. This will improve strategic capacity and, over time, release significant efficiency gains that increase the resources available for patient care. Our initial view is that the number of Trusts should be reduced by at least 50%. Fact not one of the super existing (amalgamated) Ambulance Trusts have provided any savings, or improved its services, and this has been communicated to Government by BASP and others in the past.  Big is not better, and we feel it will not provide any material benefits or savings for the public. THE BASP PANEL VIEW OF THE BRADLEY REPORT. Far from being a long overdue Independent review of Ambulance Services, the Bradley Report is biased towards its servants wishes (that of the Ambulance Service Association The NHS Employers Trade Union) It is a further expansionist attempt by the larger Ambulance Trusts to expand into areas that they (the ASA) consider to be prime and ripe territory for their selected individual member trust members to expand and obtain additional salaries for Executive Directors who will have command of far greater budgets together with additional staffing numbers. The vision of  The Reference Group (this group is not identified ) but appears to be consistent with prior published aspirations of many NHS Ambulance Trusts, Examples are continually given of WYMAS, EEA, SYMAS, Greater Manchester, London, NEAS, TENYAS, Hereford & Worcester, Coventry & Warwickshire, Essex and Kent. All being bias towards Large Ambulance Services all of whom are geared towards expansion and many that have been identified as failing services. THE Vision : Running Ambulance Services, Running NHS Direct, Running Doctors Out of Hours services, Running NHS logistic and Communications Services. Motivated by managers who have a desire to be leaders and managers, rather than those with clinical or operational experience (3.12) Are the public to believe that ambulance services could improve the speed in which 999 calls are answered, or that that they will implement overall clinical support or governance arrangements within enlarged control rooms ? Based upon current practice the Public have a right to be concerned, having been given five years to achieve acceptable targets as set by themselves, they have failed, and many have fiddled throughout all of the ORCOM Times to the extend that they have continually endangered Public lives through late arrivals and are now considering that those same targets should now be ignored or reset to suit managers or Trust Directors best interests. BASP view is that a target set 30 years ago is as important today as it will be tomorrow in that the Public should not have to wait for a longer period that would be considered reasonable. The 14 Minute Target was set against a 12 minute average for ambulances to arrive in 1970 in a city or urban district, and the 19 minutes target was set against the 18 minute average for ambulances to arrive in 1970 in a rural district. We can see no sound reason as to why these should be changed today and they must continue to stand. The 8 minute target was introduced in a effort to reduce the death rates for patients suffering from Cardiac and Breathing problems. The simple basis being  A person could survive without breathing for 4 minutes, after 8 minutes the chances of survival reduce below 50% and at 12 minutes the brain will be moribund and resuscitation may well be futile . This is a hard target but if managed in a different manner is could be achieved it must however not stop the ambulance response as a back up. Further considerations must be made to the NHS Services Act and Ambulance Services and the consideration of Prime Core Duties:  Provision of an Ambulance Transport Service free of charge for any person who falls  ill or suffers and  accident in a public place, or an  accident in the home. and Provision of an Ambulance Transport service free of charge for any person upon a Doctor or Dentist calling who is certified as being unable to be transported by any other means of transport. BASP consider that Care and Treatment prior too, and during the course of transportation has to be considered a Prime and Core duty. We would recommend that Ambulance Services should only undertake these prime Core duties as is the Public Expectation. It is unfortunate that since becoming part of the NHS, management have expanded operations to an extent that the Core and Prime duties have been continually eroded to the detriment and costs of the individual services themselves, as have the importance of standardisation of Training, Equipment and Vehicles that have been left to individual whims, fancies and desires. The example that 77% of Emergency calls result in an Emergency Patient Journey and that 40% are admitted whilst 50% could be treated in the home or community. With Doctors now only working 8 Hours a day and with weekends having no cover at all. 77% of the week will result in a 999 call or attendance at an A&E. Despite all of the Governments promises that Doctors are still available  Out of Hours , they may be!, BUT the General Public find that presenting themselves to the Ambulance Service or directly at an A & E Department means that they may well see a Qualified Medical Practitioner quicker rather than later, this gives the Public the reassurances that they want, wish, and desire, when they or their immediate family suffer a crisis. Whilst the survey may have given figures of 40% being admitted for further treatment or investigation, no mention is made of how many of the other 50% needed an X-ray, or other observations for possible head injuries, fractures, ligament injuries, pain relief or if this was down to plain illness or sickness that could have been dealt with by simple prescriptions in the home by many qualified GPs 4.11 The potential of One Million patients (one third of the total) benefiting from swift advice or treatment closer to home is a possibility, The BASP Panel would suggest that this was provided by the GPs in the past, and it is due to the withdrawal of these G.P. Services that this problem has manifested itself, resulting in extra money being poured into NHS Direct and Out of Hours services at far greater amounts than would have been required to maintain such services under a patients own GPs control. The saving of 6,000 p.a. has now cost 60,000 p.a. The Ambulance Clinician ? The Panels View is ;- Unless they actually see and view the patient they should not be authorised to decide the response. Ambulance crews who attend incidents especially suitably trained Ambulance Technicians are and have always been capable of deciding which patients are time wasters, and those that could be referred to other resources. The other resources have in the past been GPs services and in the past 40 years to the panels knowledge the Ambulance crew have been able to order via control attendance of a G.P or Midwife. Paramedics should not be tied up with treating incidents to the detriment of the more serious cases, which appear will now be dealt with by First Responders the lesser trained of all the possible responses, who may be left in an unadvised situation that could be way outside of both his/her training and experience, and which could produce traumatic experiences to such lay persons who would be inexperienced in dealing with death or near death. The report refers to  Ambulance Clinicians  E.C.P.s  and P.T.S. Staff all being involved in Home visits and undertaking diagnostic procedures both in and out of hours. BASP Have extreme concerns that PTS staff are to play an increasing role in undertaking diagnostic procedures in patients homes. Why the need for ECPs instead of Community Nurses is it again a method of plugging a gap? Why the need for  Ambulance Clinicians to undertake home visits for Doctors Special Fall teams, most elderly falls are within sheltered, nursing and care home environments these are run more so by the Private sector, and appropriate arrangements should have been in placed for a Doctors attendance or for the internal staff to be suitably trained to deal with these. The BASP panel wonders why the need for specialist Fall teams when this could and should be addressed by other means We Agree that Strokes should receive specialist treatment and special consideration these account for by the most debilitating problems, and they absorb vast resources unless treated at a very early stage. The key points 4.27 to 4.33 are well understood, however BASP have extreme doubts on the ability of Ambulance Services to achieve these key markers with any form of governance. There own resilience to change, their ability to fiddle existing figures, instead of actually showing the true picture as it is, creates very great doubts that these self same individuals can possibility undertake governance in any form unless it is  without responsibility . The benefits in chapter five place great reliance on access to the Electronic Patient Records by the Ambulance Service, by NHS Direct, and by the Out of Hours Services. Six years into the Police National Programme for IT sharing has still only produced up to 50% support. The NHS is only three years into its programme. BASP would warn that without essential National access the proposals made will not be clinically safe or achievable Big is not always beautiful, the larger the organisation the less flexible it will be to local hospital needs, within Ambulance Services it can create greater problems than they solve, and as yet we have not discovered a one cap fits all situation in ambulance services, which due to their varied topography, geographic population, and other such variances of abundance will find that responding to local needs and variance will not be a possible option for larger services. BASP have advocated that all Ambulance Services should be based upon administrative county borders, and that the only exceptions to this rule should be where certain districts have an overlapping responsibility. With more Hospital Governing bodies involving Local Authority representatives when these come up against a super Ambulance Trust the individual needs of the local population will be out weighed by the Ambulance Trust own purported needs as is happening within Scotland and Wales. Local County Ambulance Services, with a National standard of provision, which is adaptable to meet with the individual needs of the population. The larger organisation in ambulance services, has been proved to have the lesser clinical or quality assurance. BASP refer to the CHI Reports for Ambulance Services produced during 2002 and 2003 as evidence, this situation we feel has not and will not change. BASP feel that the recommendations are not achievable without extreme and substantial investment, that they are expansionist to the extreme and will be to the detriment of the General Public. This Government allowed G.Ps to opt out of, out of hours care, without having in place a suitable tried or tested alternative. They are now attempting to plug that gap by using cheap and in many cases in-experienced alternatives as a way of saving money. To fill that gap with suitable qualified Doctors is costing this Nation far more money than would have been saved through paying G.Ps a reasonable payment for undertaking these duties. The Department of Health and the Bradley report are placing a considerable reliance on the implementation of IT access to electronic patients records, this is still in its earliest stages of development and without such access BASP would consider it dangerous to venture along un-trodden pathways where many General Practitioners may fear to tread So far none of the existing amalgamated Ambulance services have managed to save any money, or provide other than a very limited improvement in services. The Panel have extreme concerns that any of these NHS Ambulance Services understand the principles of Governance, when they have confidently fiddled figures to meet with perceived targets and the Government have allowed this to continue, unabated without any fear of retribution ,as it became in the Departments interest as well to show that improvements were being made, even though matters have been shown to have worsened over the past few years. The Panel feel that for a report to be useful the depths of truth must be investigated. This can only be undertaken through an Independent inquiry. The Bradley report is no such inquiry it has been formulated to meet with the ASA (ambulance Employers Union) targets for looking after the few. It allows for reductions of the number of services so that any dissenters or critics within the ranks can be relegated. It is far from Independent and is an expanded ASA view of domination in order to improve the salaries of those that are paid on the basis of Responsibility (numbers under ) and Budgets. The Panel maintain that the current attendance times should not be changed, what is achievable by some, should be by all. The public will turn towards ambulance chasing legal beavers to obtain even greater damages through later chances of survival, and greater use of the legal system to obtain compensation and damages this will be costly to the NHS. There is an even greater possibility, that charges could be considered for corporate manslaughter, if these recommendations are accepted and implemented without further consideration and BASP would advise that an Independent Inquiry should and must be implemented. The Panel are extremely concerned that the eventual aim of the Bradley report is to reduce overall costs, through amalgamation of Trusts with a target of a reduction by 50% This will mean that Control rooms will be dealing with far greater numbers of calls without the infrastructure or technology. The Panel have severe concerns with regard to the conflicting indications (a) by the Bradley statement that Ambulances costing 120,000 will be replaced by Super Paramedics with people Carriers and (b) A statement by the Government that Ambulances will not be reduced without defining what an ambulance is or if this means a two qualified crewed manned vehicle.? The Panel remain concerned that to date all Ambulance Trust amalgamations have not saved any money, they have in fact cost substantial additional money all without any subsequent savings or increase in performance. P.A. Littledyke Chairman BASP Panel PRIVATE & CONFIDENTIAL ANNEX The Panel have extreme concerns with regard to ability of Ambulance services, post Bradley to cope in the event of a major incident. The Panel have extreme concerns post the London Bombings, that the London Ambulance Service had to instigate procedures of mutual support from all the surrounding Ambulance Trusts which resulted in Ambulance Movements to support London, from as far away as Northampton and Lincolnshire, and the South Coast of England. This is in the light of, but what can only be considered to be 4 smaller scale incidents, resulting in a considerable number of causalities, which had a far higher than normal available attendance of Doctors on scene, and we understand the involvement of Private, Voluntary, NHS, Ambulances in numbers amounting to around 100 vehicles. (not all Ambulances with patient carrying capability) We are deeply concerned that there will be a profound inability to cope in a major 7/11 incident or aircraft crash. The final figures indicated some 47 severely injured, 50 + deaths, and a considerable number of lesser injured, which also includes substantial numbers of  the worried well From later unverified reports these appear to be in the region of some 6-700 individuals. The BASP Panels concerns are that with the projected changes, that we understand are already being instigated, in that Ambulance Paramedics will and are undertaking triage of patients in order to reduce the numbers attending A&E Departments, and with so many Doctors present at the incidents, who should all be able to triage. We would question, why is it that so many casualties were taken by Double Decker Buses and other transport to The Royal London and to other Hospitals across London. Also why was it also required that the Police needed to provide drivers for Ambulances, and we would question as to:- if this was due to the complete lack of two man qualified Ambulance crews attending the incidents ? The Panel have severe concerns that from viewed T.V. reports of services arriving at the varied sites, that it would appear that no prior consideration was given to the possibility of possible secondary devices being actuated by sirens, radios, or phones on approach?. It was also noted that fire service personal were dressing for possible Chemical or biological attack. However Doctors, Ambulance, and Police Staff were not so prepared. Decontamination did not appear to be the order of the day, and it appears from an early stage that this was largely ignored by many of the services attending. With updated terrorism Awareness advice from the US Air force anticipating that the  Worried Well (psychological Casualties) will be on a 5 to 1 Was this taken into consideration and how was this addressed by the Disaster Response Teams or the Health Authorities and were arrangements made to relocate or accommodate these persons on a temporary basis other than at hospitals? The panel are concerned that there was a substantial delay in establishing a casualty bureau when this should have been established as a priority within 20 minutes of the initial incident. Capacity creation ? Quote (David Amos Director of workforce UCH London Hospitals)  creating the capacity to deal with the injured began as soon as word reached those that could help. The extended team which made decisions was invented during the crisis of the day itself , some of this was planned  The Panel have extreme concerns with regard to Hospital capacity creation, i.e. emergency discharge planning and the resources encompassed and this was via a Hospital that had rehearsed Emergency planning within the a month of the incident ! In view of the increasing number of questions being raised, and with the prospect of less Ambulances being deployed with a capability of providing transportation, and the emphasise on Paramedics and others treating on scene and discharging patients:- The Panel highly recommend that an Independent inquiry be established to investigate how the NHS Ambulance services will cope post Bradley as we do not wish to see yet another London Ambulance Service failure due to a Chief Executives or Trusts decision to further reduce services and only finding that the services are unable to cope when the suggestions go live which will become a  to late situation for the Public as well as for the Government and all those working in Ambulance Services ? Peter A. 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