Isle of Wight Ambulance Service , an Introduction

ISLE OF WIGHT AMBULANCE SERVICE - IN NEED OF EMERGENCY RESUSCITATION

The Isle of Wight ambulance service is struggling to cope with poor management decisions, under resourcing and stealth cuts to the already limited services.

These views are expressed in is piece of work reflect the very real fears and anxieties that can be heard being expressed daily in the control room, ambulances and crew rest areas of the service. With all the media attention currently being focused on the Government’s spending cuts and the NHS reforms, the frontline staff of the service would like to share, how already, the management of the Isle of Wight ambulance service are planning to cull front line services to cover up for their poor management and to protect their expanding numbers.

UNDER RESOURCED

The Isle of Wight Ambulance is the smallest of the NHS run ambulance services covering the UK, and is the only service not managed as an independent NHS trust, instead it is controlled by the Isle of Wight NHS Primary Care Trust. All other ambulance services on islands around the UK are either managed by mainland services, the Silly Isles by the South Western Ambulance Service NHS Foundation Trust, the Scottish islands by the Scottish Ambulance Service. The channel isles and the Isle of Mann each have their own ambulance services but these are independence or local government run services.

The Isle of Wight service provides for a population of approximately 140,000 island residents plus the many thousands more who visit the island each year. In terms of the level of emergency ambulance cover the Island service provides, it has the lowest number of emergency ambulances available of any of the island services for who figures are available.

The Guernsey Ambulance and Rescue Service, providing cover for some 60,000 residents has a total of 5 emergency ambulances available staffed by some 45 staff, equating to one ambulance for every 12,000 individuals. The Isle of Man is even better resourced with 42 staff providing 9 emergency ambulances to 80,000 residents, or 1 for roughly every 8,800. Jersey has chosen to publish its figures. In contrast the Isle of Wight with a staff of 132 has a fleet of 9 emergency ambulances, but on an average day only 4 are in use equating to 1 vehicle for every 35,000 residents. Even if every vehicle was to be put into use there would only be one emergency ambulance per 15,500 residents.

Whilst it is fair to say the service has up to four rapid response cars, an emergency care practitioner unit and 5 high dependency / patient transport vehicles these are not full emergency ambulances, and it is within these resources that the management services are looking to reduce resources even further.

For major events such as the Isle of Wight festival, extra medical cover is made available to cover the festival site, but the cover is purely for that site and does not allow for festival goers needing medical assistance visiting anywhere else on the island. 2 years ago the rest of the Island could enjoy the support of the 4 emergency ambulances, 4 rapid response cars, the ECP, a clinical supervisor, a senior experienced paramedic manager, and 2 high dependency vehicles. This extra cover comes at a cost, the campsite is looked after by a private medical service, the concessions / funfair area by volunteers from St. John Ambulance and the main arena by staff from the Isle of Wight and South Central Ambulance Services. This year, island staff who should be covering the rest of the island have seen their shifts changed to providing cover at the festival.

STEALTH CUTS

Historically the Island had 4 ambulance stations, one central in Newport, on to the west of the Island in Freshwater, one south in Shanklin and one to the east in Ryde, providing a total of 5 emergency vehicles. Around 5 - 6 years ago Freshwater was closed with the loss of the vehicle, leaving the nearest ambulance station some 14 miles away. Not content with this in December 2007 the stations in Ryde and Shanklin where also closed with their 2 respective ambulances being moved to Newport. This now means at certain times of the day there is no actual ambulance cover anywhere on the island apart from Newport.

And its not stations that have gone, a fleet upgrade in 2008 saw the disposal of 6 emergency vehicles, 5 Mercedes and 1 LDV, to be replaced with 4 Vauxhall units, and again in 2009, two all terrain 4x4 vehicles where replaced by just one new vehicle. Somewhat startlingly for a service which covers a mostly rural environment, this vehicle, a Nissan X-Trail converted to carry a stretcher is the 4 x 4 vehicle capable of carrying a stretcher patient in the service.

Amongst these cuts was the cutting of the High Dependency Units from 2 vehicles at weekends, a day shift and an afternoon / evening shift to leave purely a day shift crew. Then around 18 months ago, following the appointment of the current Head of Ambulance Services, Mr Chris Smith, a move was made to remove the clinical supervisors. This was done by re-assigning the duties of some, whilst using those remaining to fill gaps in ambulance crews. After a period of working in this nature the management used the argument that it had been proven that supervisors where not needed and so the role ceased to exist.

Originally there were 8 clinical supervisors, 7 in full time posts and one post being used to develop potential future supervisors providing 24 hour cover 7 days a week. Aside from the day to day management of the service, these supervisors would attend any large incidents and incidents involving other emergency services to manage the ambulance resources and liaise with the managers of the other services. In addition there were 2 non emergency patient transport supervisors, who whilst experienced in their role, where not paramedics. After showing that supervisors where not needed a restructuring took place which replaced the supervisors with 4 station managers, little more that overpaid administration assistants, one of whom is not a paramedic.

This individuals, titled Operational Support Officers provide little operational support where it matters. Only one, the non paramedic, will attempt to respond to incidents, whilst the others actually refuse to attend incidents. Cover has been dropped to the hours 0f 06.30 to 22.00 Monday to Friday and 06.30 to 16.30 at weekends. Despite working fewer hours and being non operational these individuals have been rewarded with higher pay grades. For an operational paramedic, refusal to attend an emergency call is in any other service a reason for instant dismissal, not so however it would appear on the Isle of Wight.

Of those not appointed to the new role, one was given a post dreaming up new policies and procedures under the title of Clinical Development Manger, again at an increased pay grade, 2 were redeployed to a role answering non emergency telephone calls and screening 999 calls to find reasons not to send emergency ambulances to 999 calls whilst the last paramedic lost their supervisor job, being forced to take a career step backwards.

In recent months a similar pattern has developed with the emergency care practitioners. These individuals are highly experienced paramedics who have undertaken addition training to degree level to allow them to carry out more in depth patient assessments, prescribe a limited number of antibiotics and use procedures such as wound suturing. The Isle of Wight Ambulance service’s emergency cover was centred around 8 teams of staff, each team having one ECP. In the past 2 years one ECP has left to teach in further education, 2 have retired, 2 have been moved into administration roles and one has had a non clinical management role invented so as to remove that individual from the operational pool, leaving just 2 ECP’s working.

There is no plan in place to replace any of these ECP’s, instead the management are planning to introduce a watered down diluted version of the ECP, termed paramedic practitioner, being asked to carry out the same advanced role as the ECP, but with a fraction of the training.

With supervisors and ECP’s disposed off the next target for the stealth axe are the rapid response cars. For the past few years there have been 4 of these cars rostered on duty 7 days a week, 2 cars starting at 06.30 each morning, one at midday an one at 13.00 in the afternoon each car then being on shift for 12 hours. On average each car will respond to between 4 to 8 calls a day, although management deny this claiming this is the daily total for all the cars combined.

Over the last couple of months it has become very apparent that when gaps appear in the ambulance crews due to leave or illness, the rapid response car paramedics are being moved off the cars to cover these gaps, leaving the cars not covered. Strangely such gaps in the RRV cover are left as gaps. With half the emergency provision being provided by the rapid response cars, this practice can see 50% reductions in operational emergency cover. The very real feeling now amongst staff is that we will shortly be told that management can ‘prove’ the response cars are not required, and so the Island will lose yet another large chunk of its emergency medical cover. One of the Support officers has even hinted this is the case stating that plans are being made to replace the 4 RRV’s and ECP with 1 ambulance and 1 paramedic practitioner, 5 resources being cut to 2.

The Clinical Development Manager has even gone as far as to state that management have figures which ‘prove’ that between midnight and 07.00 each morning only 2 ambulances are required. Those that heard this declaration where left unsure if it was said as a poor taste joke or a true insight into the future plans of the management of the service.

With modern ambulances being constructed in such a way that they can only carry one patient on a stretcher, even a small road traffic accident involving two family cars, could on the Isle of Wight very quickly outstrip all the available ambulance resources. The loss of supervisors to manage these accidents, ECP’s to treat the minor injuries and now RRV paramedics to provide support whilst awaiting ambulances will lead to injured individuals being left with no paramedics available to care for them, potentially for quite prolonged periods of time.

Even with current resource levels being left as they are, patient’s are experiencing unacceptable delays waiting for emergency ambulances to transport them to hospital. Recent examples include a major traffic accident less than a mile from the island’s hospital, which whilst an ECP and an RRV paramedic where on scene at within minutes, the first emergency ambulance did not arrive for some 30 minutes and a second vehicle did not arrive until 45 minutes after the crash. The management reason - they were stuck in traffic! RRV paramedics daily report delays of around an hour for emergency backup for unwell patients, and one recently was very upset at being made to wait nearly 2 hours for emergency backup for a time critical patient.

EXPANDING MANAGEMENT

At the same time as the operational cover is reduced, management has swelled, with numerous staff being given promotion and pay increases. Prior to the appointment of Mr Smith in December 2009, the service had 10 senior managers and 8 clinical supervisors. Of those original 10, one as promoted into the higher levels of the trust, one retired and one was forced from his job, despite being more capable than any one of those left in post. Since Mr Smith’s appointment and against what he termed as a management restructuring the service has now 9 senior managers, 4 Operational support Officers, 3 Clinical Support Officers, Pathways Clinical Lead, 4 Health Emergency Communications Support Officers, a driving instructor and recently a post supporting a senior manager has been invented so as to remove an ECP from operational duties. No new staff were brought in from external sources to cover these new management roles, instead being taken from operational roles, the gaps their promotions left remaining unfilled or even lost.

Despite this increase in management, staff truly feel it now harder than ever to talk to management and indeed the senior managers have moved to offices now only accessible by a security controlled door.

POOR MANAGEMENT

At some time or other every employee will complain that their managers are poor or have lost the plot, but with the Isle of Wight Ambulance Service the evidence of this is continually mounting up. Aside from the issues around resources the management of the Isle of Wight ambulance have made some truly mind blowingly awful management decisions.

For many years the control room used a CAD system which had proven reliable and robust. Following a move to take over managing the out of hours GP service the management at the request of the various GP’s looked to a new system which would combine the control of both emergency ambulances and GP telephone calls into one system. Initially management went to a small software provider who had experience of managing GP calls, but not of emergency ambulance services. Combined with this system was a move to introduce mobile data terminals into the ambulances, something which whilst routine across the rest of the UK, did not exist on the Island. The system was subsequently introduced with little training for the staff and no trial of the software or hardware.

The result was an unmitigated failure. The vehicle terminals were HTC mobile smart phones, which suffered horrendously from loss of signal, and as they needed to be constantly left on internet browsing to work, their batteries lasted normally for merely a couple of hours. It was common place for emergency calls dispatched to these phones to be received with key details missing, a frequent example being onto a postcode given for the emergency call, address details and the nature of the call lost, and in some cases the call did n arrive on the phone until some hours and on a least on occasion a whole day later.

Added to the impossibly small size of text on the screen, it became plainly apparent within hours of being introduced this system would never work in the way an emergency service needs such a system to work. Despite this the service was saddled with this system for several months before someone finally had the courage to admit the dangerous failure of this system and pull the plug on it. Result, the head of the service at the time, and so ultimately the person responsible was promoted within the wider PCT to become responsible for financial sustainability.

A second attempt to introduce a combined CAD / GP / Mobile Data Terminal (MDT) system has been at best only marginally more successful, and then some would argue against this having any degree of success. Rather than look to a system established and proven to work already within the NHS, again the service choose to look to the unknown The second and currently used system is one which is in use with various European ambulance services, but not within any UK NHS services, and then is not used to control both emergency and non emergency services. This system cost significantly more than the previous attempt and to a degree there was some effort made in testing the system. Several managers did however receive funded trips overseas to see the system in use.

However even with this there are significant problems with both the software and the technology needed for the system to be truly effective. The system relies on the mobile phone 3G system, which at management’s own admission is poor at best on the Isle of Wight. It is still common for an emergency resource, ambulance or RRV to arrive at a scene before all the details are received by the MDT. On a daily basis this system has faults occurring, which when reported are, dismissed as trivial, dismissed as being a result of the technology issues, dismiss as user error, or most frequently merely ignored. An error reporting book introduced for staff to report these problems and for managers to record an acknowledgment of the report shows no entries by any managers since before Christmas, nearly 6 months worth of unacknowledged system problems.

Within control the movement and attendance at calls of the vehicles cannot be accurately recorded, and control staff are resorting to having to manually enter information that the system should have automatically recorded. A recent visitor to the control room from a major mainland service reported that they could not believe that the control staff were being forced to use such a poor, ill thought out and unreliable system.

In with the actual control system there has been the introduction of a system called pathways which is designed to award some degree of priority to the 999 calls so that ambulances are sent first to who medical need is greater. The system is meant to all show those for whom a short delay would be clinically safe. This triaging does impact on how ambulances respond, either travelling on blue lights, or under normal road conditions. Most mainland services use similar systems, but with some preset circumstances over riding the actual final priority of the call, which the Isle Of Wight has chose to ignore, such as any patient in the public gaze should have an emergency response.

Pathways has also led to yet another management post, that of Pathways Clinical Lead. This role was never advertised for anyone to apply for, and for most the first anyone knew of this role was when an email circulated informing all staff that the Head of the Service’s partner, herself a paramedic, had been appointed to the role. Prior to her appointment she had been working as a telephone clinical advisor, a role which nationally attracts a salary at what is termed Band 5. On the Island this role is paid at the higher band 6 salary, many feel purely because it is undertaken by this individual and her best friend amongst others.

On any given day, paramedics can be heard expressing real concern over the appropriateness of these triage decisions, and many fear it is inevitable that a patient is going to be wrongly triaged as being safe for a delayed response and subsequently dying before an ambulance arrives. Recent examples include a non emergency response to someone collapsed unconscious in the street, whilst a trip and fall with no loss of conscious was given a emergency response. Interestingly pathways does for some conditions give the recommendation that an ECP should attend the patient, which could be a real challenge in a service with no ECP’s.

One group of patients the paramedics feel particularly concerned for are the elderly who have fallen and are unable to get up. To paramedic this could signify injuries such as a broken femur, which can be a life threatening / life changing injury. Injuries aside these patients are put at risk of hypothermia if laying in a draught or on a cool floor, of pressure sores which can start to develop with as little as 2 hours immobility and associated with immobility the risk of conditions such as blood clots and pneumonia. Despite this, these patient’s are routinely assessed by the triage staff as safe for a delayed response, which can and frequently does lead to many hours delay before an ambulance arrives

The MDT introduction also the introduction of electronic patient reporting, essentially a laptop computer in the back o every ambulance / RRV for the paramedics to record their clinical findings on. These where introduced to the staff as being the golden future, reducing the workload and making recording of clinical details easy. Again this ha proven to be groundless promises which have not been delivered. The software is seriously flawed, something which management refuse to accept. The software is prone to losing entered data, in particular patient’s names and dates of birth and recorded clinical observations. Recently it has been found that whilst the locations of violent and aggressive patients are recorded within the system, the information is not made available to crews should a call be received to attend that patient, leaving crews vulnerable to attack

Staff were told the system would automatically electronically capture the observations from the monitoring equipment used on the ambulances, removing the need for staff to spend time entering this information. The information is meant to then be automatically passed to the Emergency department at St Mary’s Hospital so that they are aware in advance of what patients are on there way into hospital. For patient’s referred to their own GP rather than hospital an electronic referral is meant to be passed automatically.

Put simply none of this happens. Indeed the problem of the transfer of data to the emergency department has this week led to management issuing a memo stating that because of the problems and delays occurring with the transfer of data, crews are no longer required to wait in the emergency department but simply pass the patient’s name to the reception staff who will then monitor the system waiting for the data to arrive.

The system was meant to remove the need for all paperwork including the forms used by paramedics attending deaths. Within weeks of the system going live a memo was issued to all staff instructing that in cases of death, the old style paperwork had to be used in addition to the electronic record system, because the coroner and police representing the coroner where unable to gain access to the electronic records.

Equally frustrating for paramedics is the case of regular callers to the service. With the old paperwork system, if an ambulance attended a patient but subsequently did not take them to hospital a yellow non conveyance form was left, detailing the patient’s medical condition and importantly any treatment given by the paramedics. Since the move to electronic records this vital asset has been lost. Now in theory a patient could call 4 times in a day, see each of the 4 different crews and not one crew be aware of each others findings and treatment.

When a response car is the first unit to attend a patient, the RRV paramedic is meant to commence the electronic record and then once an ambulance arrives, electronically transfer the record to the ambulance. Leaving aside the system’s superb ability to lose data, this transferring of records has high lighted what many staff feel is a criminal error, when entering treatment given the system. A the start of each shift all staff log onto their individual laptops, the member of staff who will be providing patient care, regardless of their grade is titled e practitioner attending, their colleague who is driving as practitioner supporting.

If the RRV paramedic records any treatment they have given, the record shows the treatment given by the practitioner attending. Should that record then be transferred to an ambulance, it shows the treatment as been given by the ambulance practitioner attending, not the RRV, in theory the record appears to forget an RRV has even attended the call. This could lead to an ambulance paramedic being blamed for an RRV paramedic’s error, or even showing paramedic interventions as being given by non paramedic qualified patient transport staff. Management have on many occasions been informed of this major problem, but continually dismiss it as irrelevant.

Staff have frequently asked that this system be withdrawn from frontline use until the multiple errors are rectified, so when reintroduced it is a useable valuable tool, not as one paramedic referred to it recently a collar and lead weight. Management’s response was to first pull a paramedic away from frontline duties to act as a trouble shooter, during which time there was some stability to the use of the system. That paramedic as now at their request returned to frontline duties, the head of communications who is, in theory, in charge of the system refuses to deal with the daily problems of he system. Within the last week a new memo has appeared asking for frontline staff o volunteer to wok with the software company, Valencia, to look at the multiple problems, but the email clearly states there is no funding available for this, which many staff have taken to mean management want the staff to work for free.

Even apparently simple tasks appear beyond the abilities of the current management. The service was recently granted the funds by the PCT to replace 4 worn out emergency ambulances and 3 worn out patient transport vehicles. Demonstration vehicles where provided and on the strengths of the demonstrators the crews requested purpose built Mercedes ambulances. Much to the surprise of the staff the PCT agreed and 4 state of art ambulances were order along with 2 Fiat based patient transport units. Senior managers again enjoyed European trips to the factory in Germany building the vehicles.

The Mercedes ambulance appeared to be as requested until they where used for the first time. The demonstration vehicle has given a smooth, comfortable ride, even on some of the island’s worst roads, however the vehicles that have been delivered are uncomfortable beyond belief. The suspension set up is such as to make the vehicle feel more like a cross channel ferry, with even long serving paramedics complaining of travel sickness for the first time ever. Management rather that accepting a problem does exist, are blaming it n the environment of the island. As for the 2 vehicles purchased to replace the 3 patient transport vehicles, these are still yet to enter service. A large part of the work of patient transport involves the use of standard wheelchairs, both for loading / unloading patients, and the vehicles are built so that patients can even be safely transported with their wheelchair secured to the ambulance’s floor. Not so in the case of the new vehicles which have been built in such a ay that there is insufficient space in the vehicle to even get a wheelchair into the vehicle, which in effect has rendered these two new vehicls useless.

PRESCRIPTION FOR TREATMENT

The Isle of Wight Service is not yet in a terminal condition, although it is not far from it. To leave the service in the hands of its current managers and with the current bloated management structure is to condemn the service to a terminal state. There are two options that frontline staff are taking about in hushed discussion.

Option 1 is the removal of the current management structure, return the service to what it had in place and was using successfully using prior to the appointment of Mr Smith, but with some pruning of ineffective quango like posts.

Current Title

Head of Service - to be retained but given a status equal to that within the PCT of Head of Nursing. Currently is role is equated to a hospital ward manager.

Head of Communication - remains as is

Head of Clinical Effectiveness - A similar role is carried out elsewhere in the trust so unnecessary within the ambulance service

Head of Civil Contingency - remains as is

Clinical Development Manager - A admin assistant to the Effectiveness Head, and equally as unnecessary with the service

Clinical Tutor - remaining as is, one of the few officers who can and does the role they are appointed to

Community Involvement Manager - Paid at senior manager salary but at best a role that could be undertaken on a part time basis by a lower paid role.

The Operational Support Officers need to be returned to working as the old supervisors did, on full 24 hour / 7 day a week rota.

The Clinical Support Officers role has the potential to be a useful role, but currently these are office based admin like roles. These staff need to be out working with frontline staff and given the support to provide the development staff need, not as is currently the case, identify needs but unable to fulfil the needs due to absence of funds.

A greater number of crews could be made available without the need for extra staff being recruited, purely by introducing more effective rota’s. Currently the rota pattern is based on an 8 week pattern, there are no set crew partnerships and half of the rota is given over to so called float shifts whereby staff do not know what shift they will be working until in some case less than a fortnight before the day. Management is keen to remove even this pattern leaving all shifts as unplanned float. In contrast many feel a move to a fixed pattern of shifts with set crews would lead to a greater number of crews being available.

One paramedic designed a 6 team rota running over 6 weeks which would have maintained the old levels of cover, 1 supervisor 1 ECP, 4 RRV’s and 4 Ambulances 24/7 whilst leaving 2 full teams, 32 staff, available to provide extra resources and cover gaps. An alternative plan put forward by another paramedic would have seen up to 20 permanent crews working a rota providing a greater number of ambulances over the 24 hour period, with other staff available for the RRV’s and for coming gaps etc. Both these plans where dismissed out of hand as they did not reflect the management desire for no rotas.

The frontline staff of the island’s service are all, a dedicated group who as island residents as well, want a service which is well resourced, and well managed. There was an immense degree of pride in that the service was independent of any of the large mainland services. It is therefore a very sad reflection on the management that more and more staff feel that amalgamation with the South Central Ambulance Service is the only way the service can survive.