While I sleep - a round up of some stories that have been sitting in my brainpan. Some of these were sent to me by readers, do keep up he good work. Please excuse any random kneejerkage - I'm drunk on lack of sleep.

The Healthcare Commission judged LAS as 'good' for both its use of resources and its services - a better rating than any other service in England.

First off, well done to the LAS for being the 'Best in the Country' - this really deserves a blogpost of it's own, but I thought I'd mention it here in case I forgot.

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A union has taken legal advice after ambulance managers posted details of the salaries of call centre staff on the internet.
Ray Salmon, of Unison, said the details posted on the internet included staff members' length of service, their grade, how much they earned, their date of birth, personnel number and what redundancy payment they would receive.

But then WMAS do something a little bit naughty - if you read the article the irony is rather rich, as other staff have been disciplined for releasing information in the public interest. (Begin Snark Mode) Also of some surprise is the sight of a Unison rep for the ambulance service doing something (End Snark Mode).

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A woman who won the title Nurse of the Year from a magazine is to leave the NHS because she is fed up with cuts and reforms.

"what I see as a waste of resources is when I'm sitting in a big meeting, and as a clinician I am the cheapest person there at £35,000 a year, and decisions are still being put off to another meeting."

She's a better person than me, if I were paid £35,000 to sit in meetings I'd probably put up with it. I can't blame her, banging your head against a brick wall wears a bit thin after a while.

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Individuals can no longer be held responsible for obesity so government must act to stop Britain "sleepwalking" into a crisis, a report has concluded.

I'm getting rather brassed off at the growing lack of personal responsibility. "It's not my fault that I'm a heroin addict", "It's not my fault that I'm an alcoholic", "It's not my fault that I kept eating after I stopped being able to see my feet". Apparently the government are force-feeding people like pâté de foie gras geese. Maybe people would like rationing brought back?

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Heroin and cocaine addicts on the government's treatment programme are being given drugs as a reward for clean urine samples, the BBC has learned.

The National Treatment Agency (NTA), which runs the £500m-a-year scheme, admits the practice is "unethical".

Here we go again. I think that there are better treatment options than hooking someone on Methadone instead of Heroin. This seems an awful, awful practice - the pressure of bribery coupled with the pleasure of being able to get high again, just on a government mandated supply. Is it any wonder that people remain on Methadone for years and years? I'm with Theodore Dalrymple and Mao Zedong on this one.

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Nearly 13,000 nurses across Finland are threatening to resign next month in a pay row, trade union officials say.

I don't think that much will come of this, I'd suspect that the union would blink first. Would that we had an ambulance union with that much power in the UK to balance the 'reforms' that the government is forcing on the NHS. Instead we have a union whose idea of representing us is to roll over and agree to everything - including an agreement that new members of staff are allowed to be treated like crap. Of course if we did strike the government would just privatise us all.

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Bloggers are now finding themselves prey to censorship from repressive governments as much as journalists in traditional media, a report says.

At least I'm unlikely to find myself imprisoned because of my blogging. There is always someone worse off than yourself.

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The BBC's online services will be made available free of charge at thousands of wi-fi hotspots around the UK.

The corporation has agreed a deal with wi-fi firm The Cloud, which operates 7,500 hotspots around the country.

I love the BBC, but this is just wrong. Signing up with a private company in order to provide content that I've already paid for with my TV license just isn't cricket. This is also I suspect a way in which the BBC is trying to get around the regulators ruling that people who don't run Windows should be allowed access to iPlayer functionality. Unfortunately, in the same breath they contradict themselves.

From September 7th.

"The BBC Trust has committed to making sure the BBC would meet calls for non-Windows versions of the iPlayer "as soon as possible" said the government statement."

Then October 15th.

Ashley Highfield... "We need to get the streaming service up and look at the ratio of consumption between the services and then we need to look long and hard at whether we build a download service for Mac and Linux. It comes down to cost per person and reach at the end of the day". He added: "We are not ruling it out. But we are not committing to it at this stage."

'Committed' to 'not committed' in the space of five weeks - I guess that the media world is fast paced indeed.

And yesterday, another turn around.

Are the people at the BBC (who still have jobs) feeling dizzy yet?

Essentially it all comes down to DRM - if the BBC were brave enough to offer content without DRM then platform agnosticism would be a trivial problem. But unfortunately someone somewhere has decreed that all content should expire after 30 days. Just like my old VHS recordings from 20 years ago. Because we all know how home taping has killed the entertainment industry.

The people that I know at the BBC are forward thinking, brilliant people. Unfortunately it seems that their management are holding them back. Give these sorts of people some power and you'd easily have your efficiency improvements. I have real sympathy for those on the shopfloor who are going to lose their jobs.

Recent news means I get to comment on this again...

Sorry.

In the dumbing down of the NHS, other healthcare professionals are to take over the job of doctors - these people normally have the word 'practitioner' tagged onto the end of their job title. There are Emergency Nurse Practitioners (who look at minor injuries in the A&E) and there are Medical Nurse Practitioners (who do most of the scut-work that House Officers used to do).

Now we have Emergency Care Practitioners who are Paramedics with some extra qualifications who are tasked to go out to out 'minor' calls and dissuade the people from going to hospital.

Research has shown that half of the people who call an ambulance don't need hospital treatment and that only 10% of our calls are 'life threatening'. ECPs are sent out to these 'non-emergency' calls in a desire to stop patients from going to hospital and to cover the lack of GPs providing out of hours cover.

I've talked about this previously, here and here.

But what has me thinking about this again is two recent news stories. In the first a Paramedic has been suspended by the Health Professions Council (on which I shall probably write later) because a young woman died.

The second is that the BMJ report that Paramedic treatment at home is 'viable' (I don't have a BMJ subscription so I can't read the original report).

It is obviously awful that a young woman died, but I honestly can't see that the Paramedic did anything worthy of being suspended. You can read the HPC report here. The patient, who had been having headaches for weeks previously and had been checked out twice and nothing had been found. Then when the patient became worse an ambulance was called and she was taken to hospital. She died five days later.

The Paramedic gets the blame.

I don't think that the treatment that he gave the patient was awful, certainly not worth suspending him in preparation for possibly sacking him. I've heard that he's previously been a damn fine 'medic.

This isn't the point of this post.

The point is that two other people saw the patient, that a hospital saw the patient - yet it is the ambulance Paramedic who is getting disciplined.

This is the tightrope that I walk every day. If I make even the slightest mistake (as in this case, not recording the patient's 'pain score'), then I can easily lose my job. I think that the reason why we are the ones to catch the hatchet is because we are reasonably cheap to train. It would also seem that ambulance trusts want to do anything to avoid bad publicity - so they suspend or sack crews in order to show that 'something has been done'.

So on one hand the government wants us to do more with some extra training (but not the 8+ years that GPs have), yet if something goes wrong we'll lose our jobs.

This government is going to have a rude shock when they realise that there aren't going to be a lot of ambulance staff willing to train up to be an ECP.

There is a simple rule that we tend to follow in order to keep our jobs.

'Take them to hospital'.

By taking the patient to hospital we are avoiding the responsibility if they later die. It is incredibly sad that we need to 'cover our backs' in this fashion, but it's the only way we keep our jobs.

Who is going to want to take that responsibility for another £2,000 a year? I know I wouldn't, and I have my nursing experience to back me up.

We do what we do incredibly well - we deal with drunks, trauma, chronic and acute medical problems. We deal with these by stabilising them and taking them to hospital. We do this very well. A bit of extra training will not turn us into Doctors, and we are fully aware of this fact. We are also mostly sensible people, and the feedback that we have got from the first set of ECPs won't have us running to join up.

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Birmingham was lovely, highlights were seeing Paul Cornell (a writer I greatly admire) speak and watching Alan Davis, Staz Johnson and Mark Buckingham work their astounding artistic magic on flipcharts.

Now I start on a run of four nights. I may be grumpy. Actually, no, I will be grumpy.

Premiership footballers who agreed to donate a day's wages to a nurses' hardship fund have coughed up less than a third of the money, organisers say

Well, wouldn't want those poor footballers to be short of money - Christmas is coming up isn't it...

From the BBC (and thanks to everyone who pointed this story out to me)

A woman who drunkenly abused doctors, nurses and ambulance staff in Leeds has been banned from calling the ambulance service in England and Wales.

Kathryn Gummery, 28, received the Asbo, which also bans her from the two main hospitals in Leeds, at the city's magistrates' court on Thursday.

Great, about time - people like these are a terrible drain on the NHS*.

An exception to the terms would be made if she had a genuine medical emergency.

Which will make this ASBO pretty much useless for the ambulance service. You see (and if there are any crews that know her, please let me know if I'm wrong) I would imagine that most calls to her are 'female collapsed in street'. Or even 'female with chest pain'. Either of these are emergency calls. Maybe she phones herself, in which case I'm sure that she has realised that saying yes to the question 'have you got chest pain' means that she has an immediate ambulance.

So ambulance Control will no doubt continue sending to her, crews will continue running to her and they will probably keep taking her to hospital.

Why will they keep taking her to hospital? Because they don't want to be the crew who leaves her at home only for her to choke on her vomit or fall over and break her neck. Coroners can ask some awkward questions and in the normal run of things the ambulance crew would probably lose their job.

They don't want to be the crew who leaves her in the street only for someone else to call. And if they call the police because she has breached her ASBO, the police won't want her either because you can't have drunks in police cells in case they die.

And I find it hard to imagine a magistrate locking her up for the breach (if only because she is the 'victim of a disease'*).

What did strike me as funny (and all emphasis is mine).

Police, hospital chiefs and the council applied for the Asbo due to Gummery's catalogue of aggressive behaviour.

"We're absolutely committed to working towards the policy of zero tolerance when it comes to violence and aggression towards our staff."

'Zero tolerance' indeed, if it needs a 'catalogue' of aggressive behaviour to force legal action of some kind.

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*OK, here is the thing - I'm wondering where we draw the line on medicalising bad behaviour. It seems that everyone is 'ill' these days rather than 'bad'. Alcoholism is a disease, heroin addiction is a disease, beating grannies up to feed an addiction is a disease and being violent towards people is a disease.

Very seldom does the thought that some people may have become alcoholics or heroin addicts just because they were chasing a bit of fun at other peoples expense come into view. There is always some 'reason' behind it, some reason why they are the 'victim'.

There is a continuum of behaviour from 'ill' stretching all the way to 'just plain nasty'. At what point do we draw the line on the continuum where we say that the person isn't 'diseased', but is just a nasty person to know?

An alcoholic who refuses treatment, keeps drinking and is a drain on the NHS. Well aren't they just 'diseased'? If so, why the ASBO?

This is definitely a topic for a post on it's own.

Once again, patients are waiting for ambulances rather than ambulances waiting for patients.

What is interesting is the reported tone of the Derry Mayor (and I may just be paranoid here), when he says about finding out what the other ambulances in the area were doing,

"Were they on emergency services, were they on emergency duty, were they transferring people and stuff like that," he said.

"I think that is something that needs to be addressed."

Which sounds very much to me like he wants to know if they were on a break, skiving or otherwise not 'working'.

Or it could be very interesting to see if they were dealing with people who were demanding an ambulance for a wart they'd had for the last three weeks. But I doubt that this particular follow-up story would make national news.

So it would seem that I'll be taking an effective pay cut this year as inflation outraces my pay packet. Unison (which, for better or worse is the main ambulance union) as agreed to a below inflation pay rise, staggered over the year.

I don't belong to a union because I begrudge giving them my subscription dues when they agree to stuff like this, so I don't get a vote. Much like I didn't get a vote to decide this current Prime Minister.

Still, what do I expect when our Prime Minister has cosy little chats with the Milk-thief.

It's an incredibly cheery thought, as I get ready for a run of twelve hour night shifts this Friday, Saturday and Sunday that the government values me so much. I'll bear it in mind as I destroy my body through shift work and unhealthy eating that, in order to protect inflation, I have to suffer a reduction in my quality of life by getting paid less in real terms than I did last year. I'll think of this as my back starts to ache from being stuck in an ambulance for twelve hours straight, only getting exercise as I carry people younger than myself down several flights of stairs.

And then our Health minister comes out with garbage like this,

"What is important is that we build on this, involving the workforce in the key decisions about the future of the NHS as we modernise patient care. Involving staff in this way is the key to boosting morale."

I can picture him smirking inside as he spouts this bullshit.

It seems that more and more often I think about getting out of this job and instead do something more reasonable, like writing for a living or working with computers. Unfortunately my computing 'A' level dates back to the years of the 8086 processor, and while I'm fairly smart about computers, I have nothing formally useful on my CV. That and starting on the bottom of the ladder (again) is just too depressing to consider.

And if I'm depressed now, I can imagine how I'll feel after my run of nights...

Job offers to the usual email address.

At least one of the Lib Dems has had a reasonable idea. Nothing will come of it of course, but it is a nice idea that gets him some news coverage.

UPDATE : Mousethinks points out an even better way of looking at the problem. One that in my blaise acceptance of abuse I'd completely forgotten about.

First off go and read this. Some of the comments are pretty good as well.

The article has changed somewhat from when I first read it, but it still seems to place a large part of the blame on the ambulance service. The last section tends to stick in the mind, especially the paragraph that reads.

It had failed to meet response time targets and was branded "appalling" and "unacceptable" in a report by a committee of AMs in March this year.

If things are unchanged since I was a nurse on a Medical ward and a Care of the Elderly ward then I can explain exactly why patients are waiting on ambulances for A&E trolleys.

The routine for a patient who needs a trolley and then admission to the hospital goes something like this.

1. Patient calls 999, ambulance turns up, does clever medical stuff and drives them to hospital.
2. Ambulance gives patient to A&E department by putting them on an A&E trolley.
3. A&E department doctor sees the patient, does even cleverer medical stuff, and decides they need admitting.
4. A&E nurse calls the bed manager, bed manager finds the patient a bed on an appropriate ward.
5. A&E transfer the patient to the ward.
6. Patient gets treated on the ward and either goes home or, if unable to return home, is referred to the social workers who arrange a care home/warden controlled place/home care package.

So where is the most common delay? It's at step 6, and this trickles back all the way to step 2.

When a patient cannot return home (for example following a stroke) the social workers need to sort out who is going to fund the care home, they need physiotherapy reports, they need occupational therapy reports, they need to run 'Multidisciplinary team' meetings and they need to do all the other arcane and hidden things that they get paid to do.

Then there needs to be an available place at a care home that the patient and family are happy with. And this all takes time, and so the patient becomes a 'bed-blocker'.

(The record for me when I was a nurse was a patient staying on the ward unnecessarily for six months while funding was sorted out)

Even if the patient can return home but needs assistance, be that daily carers or just a stairlift installation, the delays are much the same.

If the ward beds are full there is no place for a new patient, so the patient stays in A&E taking up a trolley that could have been used by the next patient rolling in by ambulance.

Which means that the A&E department turns into a medical/surgical/psychiatric ward by knocking the wheels off some trolleys and hiring and expensive agency nurse to look after the patients for a few days.

There are other delays, like ward nurses 'not being ready' for a patient even though they have an empty bed, or A&E departments being reluctant to accept new patients because it would impact on their four hour government target. But generally I would say that these are fairly minor and can be fixed by a Matron with a big stick. Or an angry A&E nurse threatening ward nurses with bloody murder...Ahem...

I think that when Mike Cassidy says, "We've experienced some difficulties, maybe one or two days every couple of weeks just when the system overheats a bit and when demand is extremely high for us.", he is highlighting that this is a cyclical thing, and perhaps people should look into why it is a cycle. Is it because in the hospital social workers and the like vanish at the weekend, leading to a Monday/Tuesday backlog of patients?

However - both the hospital trust and the ambulance service blame the number of 'inappropriate attenders', people who should have gone to their GP for their minor illness. 'Inappropriate attenders' don't block beds - they tend to slow down the transit of people through A&E, but as they seldom need trolleys to lie on they can't really be blamed for making ambulances wait with their patients for trolleys. What 'inappropriate attenders' do is make other minor injury people wait to be seen.

We can blame 'inappropriate attenders' for a lot, I know I do, but in this case their influence is tiny.

What is needed is more social workers, more care homes and more hospital beds with the nurses to staff them. There needs to be a way to move people who no longer need hospital treatment into appropriate placements much faster and there needs to be a streamlining of the discharge into care process.

But that requires money.

And I'm not the minister for health.