How long do you expect to wait for an ambulance? Ten minutes? Twenty minutes? An hour? What if the ambulance doesn’t come quickly — what would you do?
The latest official figures show that our local ambulance service, South Western Ambulance Service NHS Foundation Trust, is failing to meet national performance standards in responding to the most urgent calls.
In early March this year, a 58-year-old man who injured his head in an accident in East Street, Bridport, was given treatment at the scene but had to wait an hour and a half for an ambulance to take him to hospital.
The Yarn is also aware of a worrying trend for long delays in ambulances for patients with serious but less urgent conditions. Some people are waiting so long that they choose to take casualties to hospital themselves.
This was the case with Jo Kemp from Whitchurch Canonicorum, who collapsed with shock after tearing off her little finger in a bellringing accident. Jo lay in the church carpark for more than an hour with friends and a community first responder in attendance. In the end, despite the first responder’s misgivings, a friend took Jo to hospital in his car. Once in hospital, Jo was detained for four days for surgery and treatment.
The Yarn spoke to Jo about her experience, heard from members of the ambulance service and interviewed the founder of Thorncombe Community First Responders, which was the first group of its kind in the UK.
South Western Ambulance Service NHS Foundation Trust commented on the issues raised.
When Jo Kemp badly injured her little finger in a bellringing accident at Whitchurch Canonicorum church, she collapsed from pain and shock. The other bellringers bandaged her hand and called an ambulance.
“I can’t tell you how traumatised I was. I managed to get down from the bell tower and then the shock hit me and my legs went and I couldn’t hear anything and I just wanted to die and not be there.”
Within minutes a community first responder was on the scene and he put Jo in the recovery position in the church carpark. It was evening and getting dark and cold, so the bellringers rallied round and provided blankets and cushions to keep her warm.
After nearly half an hour with no sign of an ambulance, the first responder rang the service again. He was told that all the ambulances were attending other calls.
“The first responder said ‘this person needs an ambulance’,” Jo remembers.
After over an hour of waiting and several more calls, the bellringers decided to take Jo to hospital themselves, despite the first responder’s misgivings. Once in hospital, Jo was admitted to a ward, given morphine and put on a drip. The accident had left the top joint of one of little fingers hanging by a narrow flap of skin and over the next few days, surgeons managed to reattach it without infection setting in.
Jo stayed in hospital for four days. It took three months to fully recover the use of her hand.
Disturbing because the service is facing unprecedented demands (more than 19,000 incidents a week during December) and it is struggling to cope. There are reasons why it recently took 90 minutes for an ambulance to arrive in Bridport after a man suffered head injuries in a collision with a car outside the Bull Hotel in East Street.
“I think a lot of people would be worried and probably horrified to know the true situation. A lot of the time Bridport is not actually covered by an ambulance — and that applies to the whole of the west of Dorset.”
So says one paramedic that Yarn Magazine spoke to, on condition of strict anonymity. Altogether we spoke to three South Western Ambulance Service staff, all of whom have a good knowledge of the situation in West Dorset, East Devon and parts of South Somerset, particularly the area that stretches from Axminster and Lyme Regis down past Bridport to Abbotsbury, and then up past Beaminster towards Mosterton and beyond. For ease of reading, we’ll call them X, Y and Z.
Subjects covered below include the times that ambulances take to arrive, paramedics getting burned out with stress, dirty ambulances, staff shortages, long waits at hospitals, the imbalance between urban and rural areas, reduced overnight cover around Axminster and the need for more resources.
‘We’re always stretched for resources’
Ambulance staff say they used to expect to cover about 150 miles per shift. Now it’s more like 300.
X: “In the old days you’d maybe do four or five jobs a night and stick local, so you’d be in the West Dorset area.
“Nowadays we cover the South West of England, over to Bournemouth and Poole, up as far as Bristol and Gloucestershire, and down as far as Cornwall.
“We’ve had a Cornwall crew in Dorchester. The crew were bounced from Newquay to Plymouth to Exeter to Honiton to Lyme Regis and then they had to take a patient up to Dorchester. That’s fairly unusual but there are crews from Exeter in Bridport fairly regularly now — and vice versa — and you’ll get crews coming into Bridport from the north, from places like Yeovil, Taunton and Ilminster — and vice versa.”
Ambulance services used to pride themselves on using sophisticated data analysis to predict where ambulances would be required, and moving them to prime spots accordingly. The system was pro-active. Now it’s reactive. Whoever is nearest is sent. But nearest can be a surprisingly long way away.
“So we’ve had vehicles from Bridport sent to emergencies in Bournemouth and Poole because they were the nearest vehicle and they were kept going until they got to the actual job. That’s a one-hour / one-hour 15 minute run on blue lights. Even in the middle of the night that’s fairly dangerous, having to go at speed, but in daytime it’s even worse with all the extra traffic around and needing to be very vigilant the whole time.”
Dorset has around 38 frontline ambulances and 15 response cars. Government targets require ambulance services to get to a life-threatening situation within eight minutes, and to get a patient-carrying vehicle there in 19 minutes. In practice, these targets lead to a focus on urban areas such as Bournemouth and Poole.
”Those vehicles more often than not are put into the large conurbations so that they’re available to hit those Government targets and then the rural areas suffer because those vehicles are not available.
“In the west of Dorset we have many serious accidents because of the rural roads and the fast roads.
“One ambulance carries one person, so if you’ve got an accident with four people in it, you need four ambulances.
“If you have an accident with eight people in it, you need eight ambulances.
“So we’re always stretched for resources.”
‘The norm now is you can be waiting 45-50 minutes for an ambulance’
Y: “In the west of Dorset from midnight until 7 o’clock in the morning there’s one ambulance, from 7 o’clock till midday one ambulance, at 12 o’clock a second ambulance becomes available but then from 5 o’clock in the evening there is nothing in the Axminster, Seaton, Musbury areas and so Bridport now covers that. That means very often that you’re going down into Devon and that you often have to take a patient to Exeter… and then you get caught for a job in Exeter or Dawlish or somewhere further down the line.
“The problem with a crew from the west of Dorset being down in Torbay at night — as they have been — is that leaves no other crew available in the west of Dorset. Which means there’s then a wait for other vehicles to come into this area from Ilminster or Yeovil or Dorchester or Weymouth or further afield — so you’ve got a time-lag of 30, 40, 50 minutes.
“First responders are relied upon a lot more, not just staff-side responders but also the huge number of volunteer responders and they do make a vast difference with hitting the response times and giving life-saving treatment to people, prior to an ambulance getting there. Lyme Regis and Beaminster have fire brigade responders, paid to go out for the ambulance service, and those guys are very good
“But the norm now is you can be waiting 45-50 minutes for an ambulance to actually get to somebody, even when a first responder has gone to them, and if you’ve got a patient in a serious condition that time can be crucial because after the first ‘golden hour’ a patient has got much less chance of survival, if they don’t get the right treatment.”
One nasty job after another. Paramedics burned out
There is a national shortage of paramedics. A report to the most recent board meeting of the South Western Ambulance Service NHS Foundation Trust (SWASFT) notes that “this is having a significant impact on the service in the South West.” The same report notes 130 relevant vacancies in SWASFT (nearly 8% down on the required total)
Z: “People still talk about the old Dorset Ambulance Service. Then if there was a serious RTC or a nasty job where somebody had been seriously injured you’d be able to go back to the station, restock all of the equipment that you’d used, have a cup of tea, clean up, get yourself cleaned up and be able to prepare yourself for the next job. Now, very often you do a nasty job, you can guarantee that within two minutes of finishing that job, you’re out on another job.
“There is no time to wind down, there is no time to stop and think — ‘could I have done this any better?’ It is, literally, on with the next job, because the next job’s waiting.
“We’re working 12 to 14 hour shifts at a time and paramedics are being burned out very, very quickly with stress and just the type of jobs that we go to.
“Paramedics are not having that time to be able to sit and talk and get over the jobs and learn and move on again.
“And you need to keep learning because every patient is different and there are lots of different presentations of lots of different conditions.
“And if your mind is still dwelling on your last job, because you’ve not had time to wind down, then you’re not necessarily focusing on your next patient.”
A list of “Real Concerns” in SWASFT’s latest internal performance report notes: “The number of frontline operational vacancies is having a significant and sustained impact on performance.” Another report notes that staff are stretched and “very tired”, sickness high, and vacancy levels also high.
X says: “There are shifts in the west of Dorset that are not covered.
“The list of overtime possibilities that comes out regularly, to cover shifts that are vacant, is quite a list.”
*As we were going to press, The Yarn heard from a fourth source that recent incentives offered to staff to work overtime have included double pay on weekdays, triple at weekends, and for off-duty staff, a one-off payment of £150 if they’re able to get to the most serious incidents (such as heart attacks) within eight minutes.
“Horrendous” waiting at hospitals
Another “Real Concern” for SWASFT: “Operational time lost to handover delays at acute hospitals in December 2014 increased to 1,834 hours. A number of hospitals had handover delays in excess of 2 hours.” The year to date figure of time lost was 12,932 hours (that’s nearly 539 days)
Z: “I love the job, I love working with patients, but I can’t stand the politics behind it and the delays that we’re suffering constantly in getting in and out of hospitals.
“The government have cut resources in hospitals, and that’s having a follow-on effect on the ambulance service. Hospitals have cut the number of beds so there’s nowhere for patients from A&E to move upstairs when they need to move upstairs, which then means that ambulances are waiting to offload into A&E. I don’t know all the latest exact figures for waiting times but they must be horrendous.
“Sometimes you’ll have five or six ambulances queuing at a hospital, on a regular basis, and they can be doing an hour each. Take out six ambulances, they’re then not available for Dorset, and you start to get horrific figures there as well.
“If they could put more resources into the hospital, so that people could be moved through the system quicker, ambulances could offload quicker and there’d be more vehicles out on the road. It’s not just Dorchester, it’s Poole, it’s Bournemouth, it’s every hospital in this area.”
Dirty ambulances. No time for cleaning, or online training
Y: “Not only we do have to man the vehicles, we have to clean the vehicles, and we have to stock the vehicles, but more often than not these days the vehicles do not get checked before they go out in the mornings because very often you’ll book on to a vehicle at your start time and they’ll give you two minutes and you’ll be out the door. We’re supposed to have 12 minutes to check the vehicle, but we get two minutes and then you’re out the door and very often you don’t come back for six hours, which means the vehicles don’t get checked properly, so they don’t get restocked properly, they don’t get cleaned, which is why, if you look, you’ll see many dirty ambulances driving around.
“They get looked at every six weeks, and they have a deep clean and a total clean every six weeks.
“We should be doing them once a week as well, at least, but it’s not being done.”
Asked why vehicles can’t be cleaned when staff return to base, as it’s clearly important, Y responds: “But we don’t come back very often, and when you do it’s normally for a meal break, which is 30 minutes, and in that time you’ve got to do all your ablutions, use the toilets, make yourself a drink, have something to eat, and very often on the 30-minute mark you’re back out the door again, so you haven’t got time to clean the vehicles.
“Some crews leave their ambulance stations and they don’t come back until an hour or more after their shift should have finished. So they’re working 13-14 hour shifts.
“And also in that time we have to do online training on the computers, which most people haven’t done this year because they’re never there to do it.”
Another recent SWASFT report says: “There are risks to the Trust if staff are unable to complete training. [Human Resources] need to rethink how to get staff to do what they need to do. There is an unrealistic expectation for staff to do things in their own time. Shifts do not permit them to do this.”
How to make it better?
Y: “More resources in the hospitals, which would then free up more resources for us on the road.”
Z: “We also need to fill our vacancies and get back up to full staffing levels to be able to man the vehicles all of the time and have them in the right areas.”
X: “If you’ve got vehicles in the conurbations of Poole and Bournemouth that are not being manned, because of staff shortages, then to get the response times there they do pull in vehicles from other areas — which leaves gaps in those areas. So, yeah, more resources in the hospitals, and we do really need to get our staffing levels up so we can all do our best for the patients . That’s what we’re here for.”
National performance standards
Red 1: immediately life-threatening. Conditions where speed of response may be critical in saving life or improving the patient’s life subsequently, for example, heart attack, trauma, serious bleeding.
Red 2: serious but not the most life-threatening. For example, conditions such as strokes and fits.
All NHS ambulance services must respond to 75% of Red calls within eight minutes. Not necessarily with an ambulance; it could be a paramedic in a car or on a motorbike. If a clinician attending to a patient requests an ambulance, 95% of patients should be reached within 19 minutes.
South Western Ambulance Service NHS Foundation Trust is doing better than most other trusts nationally, but in the third quarter of 2015/15 its performance figures were below national targets. Figures fluctuate from month to month. In November 2014 (to use the latest figures available to The Yarn), SWASFT’s Red 1 score was 74.68% (against a national average of 71.80%) and its Red 2 score was 70.81% (against a national average of 63.38%).
The ambulance service responds
What are you doing — outside the conurbations, big cities and big towns — to ensure that ambulances get to incidents as quickly as possible?
South Western Ambulance Service NHS Foundation Trust (SWASFT) strives to reach patients as quickly and safely as possible regardless of their location. SWASFT is the most rural ambulance service in the country and there are certainly challenges in reaching patients in remote locations as quickly as we would like.
However, we have put a number of measures in place to ensure that patients get the right care in the right place at the right time. These include working in partnership with businesses and communities to install as many defibrillators as possible in rural locations and provide the training for people to use them. Additionally, the trust is fortunate to have access to six air ambulances across its operational area which covers a fifth of England’s land mass. The helicopters are often used to reach patients in more rural and isolated locations.
SWASFT is also extremely fortunate to be supported by a number of responders. There are over 2,700 including Community, Fire, St John and staff responders working across the trust’s area. Their skills are most valuable in the case of cardiac arrests, where literally every second counts. They respond as an initial, first response and provide essential skills whilst an ambulance is on its way. A network of GPs also assists us on a voluntary basis by attending certain incidents, working alongside trust clinicians.
Are staff getting enough time during shifts to do things that should be done, such as re-stocking and cleaning ambulances and doing online training?
All ambulances are cleaned and re-stocked routinely and in accordance with strict regulations. All staff have dedicated time to complete these checks.
Owing to the demanding front-line nature of the work carried out by SWASFT clinicians it can be challenging to ensure sufficient time is always available for online training. The trust recognises the importance of training and, on occasions, has offered overtime payments to staff in order to enable them to carry out any mandatory training.
A great deal of investment has also been made into e-learning packages which can be accessed remotely if required. The trust has recently appointed three new training staff (one in each division — North, East and West). They will be looking at new ways of approaching and delivering training in conjunction with front-line staff, who will be consulted during the process to ensure that any future training provision is most appropriate for their needs.
It’s a “Real Concern” for SWASFT that a shortage of frontline staff is having a significant impact on the trust’s performance. What are you doing about this?
The shortage of front-line paramedics is a national problem and SWASFT is working hard to minimise the impact that this is having on its day-to-day operations. The safety of our staff and patients is of paramount importance and it is pleasing to note that the number of vacancies continues to reduce.
In SWASFT we are “growing our own” by:
- Building a Clinical Workforce Development Strategy
- Offering access, support and funding for staff to complete the required qualification to become registered clinicians
- We are retaining staff by:
- Ensuring career development and progression
- Offering leadership training
- Developing paramedics to become specialist paramedics
- Recruiting paramedics from universities to ensure a constant flow of graduates
- Working with universities to offer students practice placements and mentorship within SWASFT as part of their courses
- Bank contracts as emergency care assistant for students while they complete their courses
Ambulances spend huge amounts of time waiting outside hospitals. What are you trying to do to reduce this?
SWASFT works hard with the 18 acute hospitals in the South West to minimize handover delays in their emergency departments.
We also work closely with its commissioners to ensure a collaborative approach to managing pressures on delivering high quality emergency care. Handover delays are reported to Clinical Commissioning Groups (CCGs) and reviewed on a monthly basis.
SWASFT is one the best performing ambulance trusts in the country for minimizing handover delays. Increasing demand year-on-year is putting pressure on every area of the NHS and we pride ourselves on ensuring our patients are cared for in the right setting.
SWASFT is also the top performing ambulance service for the number of patients not conveyed to an emergency department, where possible and appropriate. On average, more than 50 per cent of our patients are treated via other, more appropriate, care pathways within the community, either over the telephone or face-to-face, without needing to attend an emergency department.
Why is there no ambulance cover after 5pm around Axminster, so that Bridport is now expected to cover this area?
Our resources are planned against expected activity so we can ensure we have the right number of resources on duty when most needed.
Alongside ambulance stations, the trust uses facilitated stand-by points to ensure our resources can provide cover where and when needed — these stand-by points are always located where resources have good access to road networks so are able to respond quickly wherever they are needed.
Every patient across the trust area will receive the nearest, quickest, most appropriate response. SWASFT has a dynamic status management plan which allows us to move resources to provide emergency cover across all areas of the trust. For example, if a rural resource is utilised, a resource from elsewhere would be moved to a station or stand-by location to provide cover. For a map of our region and ambulance stations: bit.ly/swasft.
What could the public do to help you?
Members of the public can “Choose Well” when it comes to accessing healthcare services. If you are suffering a life-threatening emergency you should call 999 immediately. However, people with less serious conditions should speak to a local pharmacist, visit a GP or call 111. The 999 line should only be used for life-threatening situations like cardiac arrests, strokes and serious bleeding.
If anyone is interested in working in partnership with us, either to train as a responder or have a defibrillator installed in their locality, either visit our website » www.swast.nhs.uk or call 01392 261500.
Helping a frail and very elderly man back into bed after a fall, giving a distressed toddler with breathing difficulties a whiff of oxygen, or simply just turning up — all elements of being a Community First Responder based in one of West Dorset’s most remote villages.
A 999 call for an ambulance here in the countryside, reached by narrow, winding lanes, means that delays are sometimes unavoidable.
The introduction of rapid response vehicles and the merging of Dorset’s ambulance service into the South Western Ambulance Service have improved the situation.
But sometimes, it’s a member of the local volunteer network of trained first-aiders who will be the first through the door.
In their high-vis jackets, they come bearing oxygen, a defibrillator, resuscitation kit — and reassurance.
Thorncombe formed the first community First Responder group in the country and for 17 years now a team of local people has provided 24/7 cover, on call day and night — apart from on New Year’s Eve 1999 when everyone went to the same party.
It was the former postmistress Rosemary Walley who, with husband Brian, set up the group and she has been awarded an MBE as a result.
Now retired and no longer an active member she says the group has grown, but the basic ethos hasn’t changed.
“First Responders are there to provide emergency care for people who are waiting for an ambulance — that has never changed,” she points out.
“Just someone walking through the door in the yellow coat — any number of people have said to me that that sense of reassurance is worth such a lot.”
The First Responders in Thorncombe came together after a charity jar to raise money for a defibrillator was on the Post Office counter.
“But where would it go when we had it?” recalls Rosemary.
“So from there the idea grew, like Topsy.
“In the first year we managed 24/7 cover with four people!”
The local community has rallied round the group, funding the current four-wheel-drive vehicle, and a link with Magna Careline means that not only can elderly people have the First Responders as the priority number to call, but they have also been able to provide the personal alarms for people who otherwise couldn’t afford one.
In the past year the Thorncombe First Responders have been called out 100 times and they travel as far as Broadwindsor, Drimpton and Marshwood. Over the years their “first on scene” training has saved several lives and their arrival within the crucial “golden hour” can be vital in dealing with heart attacks and strokes.
“If anyone is interested in becoming a Community First Responder or finding out more information about having a defibrillator available in their local community, get in touch with us, either by visiting our website » www.swast.nhs.uk or calling 01392 261647.”
What does a First Responder do?
CFRs attend particular types of medical emergencies where it is essential for the patient to receive immediate life-saving care. This includes conditions such as cardiac arrest, chest pain, breathing difficulties, unconscious patients, fitting and stroke.
CFRs are not sent to particular types of incident including road accidents or incidents involving excess alcohol or drugs, due to concerns for their personal or scene safety.
You do not need any previous medical training to become a CFR.
You do need:
- A full driving licence
- Good interpersonal and communication skills
- The ability to observe and accurately record details
- The ability to take the lead and remain calm in pressured situations