Somehow on my 'week off' I'm busier than I would be if I were just going to work. How am I ever going to get my full Spellfire set or my next six million ISK?

(OK, nerd episode over).

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I've been spurred into writing this post for two reasons - the first is this post of mine and the associated comments, the second is this article in the Financial Times. Two quick notes on the article, if the government want to employ a blog expert I can be had for a salary of, oh lets say £25,000+. Also if they want to invite me to talk to them, I'm more than happy to spill my brains the general direction of anyone in government.

To recap - the main target that the government has set ambulance services around the country is that of ORCON. This, at it's simplest, states that we should reach our high priority calls in under eight minutes and our medium priority calls in under fourteen minutes.

The problem that I have with this is twofold. Firstly, in a supposed 'evidence-based' NHS there is little clinical reason for the eight minutes as opposed to four minutes. Secondly, and much more importantly in my opinion it directly impacts on patient care.

In order to meet the eight minute target ambulance services are removing double-crewed ambulances from the road in order to increase the number of Fast Response Units (FRUs). The reasoning is that if an FRU is on scene then the 'clock stops' and the job is a success. It's not a success for the FRU if they are stuck on scene with a stabbing, unresponsive asthmatics or with a child with meningitis.

People who are seriously sick need to be in hospital, not having a solo responder holding their hand while praying in desperation for an ambulance.

Ambulance folk can do a lot to stabilise a patient, but as a trainer of mine wisely says, "the place for a sick patient isn't the back of an ambulance". Nor is it in their own home waiting for an ambulance to turn up.

So, what are we to do? We need to check on the performance of NHS trusts, that much is certain.

My solution is to have more targets.

But targets which will have an impact on patient care.

Lets have a target where we improve the number of heart attacks that we diagnose in the home and transfer to the 'gold standard' treatment centre. I think we are at 95-97% on that at the moment. How about improving the call to treatment time.

Lets have another target where we diagnose strokes (or 'brain attacks' in the jargon of today) and transport them to a specialist centre. Of course we might need a few more places to become specialist centres first, but isn't the NHS a 'joined up' organisation?

Lets have a target where we try to reduce the number of patients with asthma who need admitting to hospital. Better, lets reduce the number of people who need to stay in ITU because of asthma. Of course it isn't the sole job of the ambulance service to do this, but our targets should inform other aspects of the NHS, just as theirs affects ours.

How about improving the measurement and treatment of pain - its something that we aren't too good at, given that in most cases our choice of pain relief is restricted to entonox or morphine. We carry aspirin, but that is for heart attack treatment, not the treatment of minor pain. We also have paracetamol for children. How about nasal diamorphine? Improving the measurement and treatment of pain will directly improve patient's experiences.

How about improving cardiac arrest survival rates. We've managed to improve this greatly over the past few years and I'll be talking about this in a later post. Unfortunately the government doesn't 'reward' us due to our improvements in this area, perhaps they should.

Time until a patient is reached is important in some cases, so we'll keep a target for reaching patients, but lets change it to only having the clock stop when a proper double-crewed ambulance arrives on scene. The other targets (like cardiac arrest survival) will be met by FRUs getting there quickly, but this will mean that there is less chance of FRUs being manned at the expense of proper ambulances.

How about a target of increasing the amount of paramedic cover in an area. Or how about a target of improving the training of people on the road? Better trained staff means better care for patients.

Maybe a target to increase the number of ambulances on the road. Even better would be a target to have a certain amount of spare ambulances. Ambulances that are waiting for a call from a patient rather than the other way around. We should have a slight excess capacity of ambulances at all times, not have people waiting for ambulances to finish with one patient before they can be attended to.

Finally, how about a 'staff satisfaction' target - a happy workforce is a more effective workforce.

Some of these targets are more important than others and by giving individual targets a separate weighting we could come up with a total 'score' that will show improvement, but can also be broken down to show where further improvement can be made. For example the number of people who get diagnosed and treated at a specialist centre for a stroke could be worth ten times as much as the number of people who get painkillers for their broken arm.

We could even keep the ORCON target, but give it a more reasonable weighting of importance.

This system would have the advantage of being better based on current evidence and would highlight areas where changes can have an immediate effect on patient care and outcome.

There is a reason why I get a warm and fuzzy feeling when I diagnose and take to a specialist centre someone having a heart attack. It's because I've done something that will have an effect on the patients well-being. It's a feeling that I don't get when I reach somewhere in under eight minutes or meet an FRU who has been on scene for forty minutes.

Right - how do I get to be Minister In Charge of Sensible Ideas for Ambulances?

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I've fiddled around a bit with this blog in an attempt to resolve some of the issues some people have had with getting a black screen when accessing the site. Let me know if it works out.

Ambulances may be spreading infections such as MRSA because they are not being cleaned properly, union leaders warn.

...At the other end of the scale London Ambulance Service has introduced on-site cleaners who work throughout the night to routinely deep clean the fleet. They also restock ambulances with fresh kit, freeing up paramedics for seeing patients. Effectively, crews bring in a dirty vehicle and leave with a cleaned one, Unison said.

It is pretty good in London to be completely honest. The 'Make-ready' crews do clean the ambulances and they do have an attempt at stocking the ambulances. Except when there isn't the spare kit on the station, in which case they don't run around to other stations to try and find the equipment, that's up to us.

We are also still supposed to check the ambulances, but this rarely happens (unless you come into work early) as our call rate is so high.

There are also random swabs of ambulances where we see if there is anything growing on an ambulance that shouldn't be there. So far the results have been very good.

It's especially good considering that the Make-ready people get paid minimum wage and work hours like 1am-5am.

Where it is somewhat let down is that due to the desire to have us rapidly 'turn around' at hospital, unless there is specific soiling of the ambulance (blood, vomit, or for me last night, large amounts of spittle) we don't have the time to clean down the trollies with detergent.

Nor do we have enough blankets to have each patient have their own separate one - again they only tend to get changed if there is visible soiling or if the patient is known to be carrying a communicable disease.

But on the whole I think that we do a pretty good job with the resources that we have - we could do better, but that would mean that the government would have to give us more money. Something that they are loathe to do.

An investigation has been launched after an ambulance took 22 minutes to reach a dying pensioner.
Ernie Rutkiewicz, 82, from Glasgow, choked on his dinner last Thursday and died in Glasgow Royal Infirmary.

The crew which attended could not be assigned to the emergency any earlier as they were on a meal break.

Under rules, ambulance crews are entitled to a half-hour break during their shift and cannot be disturbed during that period.

The meal break rule was introduced in Scotland as part of a UK-wide initiative called Agenda for Change, which affects NHS pay and conditions.

This is a sad story and I feel very sorry for the patient and his family.

Once more it is meal breaks that are 'to blame' for someone dying rather than there being a lack of ambulances to cover for the legally mandated rest breaks. The ambulance crew involved would not have even known about the call. For all intents and purposes during a rest break the crew are not being paid and are therefore not on duty.

(And it's a 'rest break', not a 'meal break', there is nothing making the employer provide an ability to eat food).

However, the last time I saw a story like this, the newspaper involved claimed that two ambulance crews were on a rest break - when actually their vehicles were broken and they were off the road waiting for them to be fixed.

I've just done four twelve hour shifts, I've only had one rest break on all those shifts. Most folks work eight hour days and would expect a break at some point.

My next set of shifts is eight hours long, and they are an absolute doddle considering our 'normal' shifts are twelve hours long.

I wonder if the investigation into this particular case will ask what other ambulances were doing? Were they covering GP who refuses to see patients? Were they rushing through the streets to a drunkard in the street? Were they going to someone who wanted an excuse to knock off work early? Where they running to someone who'd taken too much heroin? Were they trying to find a hoaxed call? Were they going to someone who just wasn't home?

It's too easy to suggest that the reason this man died was because of rest breaks as opposed to the much more complicated mixture of a lack of ambulances, too many inappropriate calls and that we are doing everyone else's job these days.

But that is less likely to 'sell' the news.

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.