Whole-system fixes needed to ambulance failures

A young man has a seziure, falls and sustains fractures. Lying on the ground a passerby phones for an ambulance. On the phone call they are instead offered a consultation. The police end up ferrying the young man to a hospital where he requires surgery.

This story as reported in the Scotsman today may at first sound like a failure in the ambulance service, but that would be to fail to see the bigger problem. It is better understood as a systemic failure in a network of public services which requires systematic action to resolve it.

The reason the ambulance service gave for not attending was that it was not a life-threatening condition. Yet the ambulance service has much of its time dedicated to ferrying patients (often elderly of with mobility issues) to appointments.

The pressures of operating both as a taxi service and as an option of last resort in life-saving circumstances appears to leave little capacity for everything in between. Yet the idea that an ambulance is for life-threatening situations only is not one most people will recognise. Most people would identify a range of conditions (including being immobilised or being unsure whether a person should be moved) as situations for an ambulance.

But while there is reason to believe that Scotland's ambulance system is in need of reform, that is only part of the problem. A crucial aspect is highlighted elsewhere in the article when a hospital spokesperson makes clear that a 'whole system plan' to reduce ambulance stacking was deemed 'unachievable'.

This is the crux of it. The problems in the ambulance service is displaying downstream symptoms of upstream problems. Hospitals are often overwhelmed and unable to process patients arriving in time to accommodate them swiftly at the hospitals. So they are stuck in ambulances and the ambulances stack up.

Ambulances sitting stationary in a queue at a hospital can't attend emergencies. And in any case, there are other problems even further upstream. One of the reasons that ambulances are increasingly being called on as a taxi service is that because care services are greatly weakened, the service is dealing with increasing and time-consuming mental health problmens and elderly people are becoming more isolated with fewer networks.

We are relying on whatever public service remains to make up for those that have atrophied. And to get a full picture, there are then more problems induced downstream from the ambulance service. If the police are driving an injured man to a hospital, they are not available for police work.

In fact many serving in the police report that as much as a third of their time is spent dealing with what is effective social work cases – mental health or household crisis where there is no-one else to turn to.

This is the result of a systematic failure in the model of public service delivery we have. By separating and isolating each part of the service as a 'cost centre' which can then be monitored via performance indicators, those tasked with resolving this systemic problem are the people who presided over its genesis and are approaching the task with the same tools that caused the problem in the first place.

Overwhelmed ambulance service? Look at the performance indicators. Everything at breaking point? Reduce the service level to the level you think you can deliver within the system you have, resourced as it is. Removing failure has already been ruled out, so cutting is what's left.

That the people who preside over the whole system are announcing a 'whole system' solution to be unachievable demonstrates that our current management regimes are not capable of the kind of all-system action that is require.

It is probably true that no single controlling senior management team can, on its own, make the changes necessary. That's why it shouldn't try. Rather it should devolve management of services to those delivering services and allow a more 'organic' reform of health services by coordinating between a lot of moving parts which are each empowered to transform themselves.

This is what Common Weal means by a medically-led health service. It's why we need an EMT-led ambulance service.

But in the end this is a public service and so it should serve the public. The service level of an ambulance shouldn't be a matter of what a manager decides you're allowed. The service level should reflect public expectations and the politicians should create a structure which delivers that – or move on.

You can find out more about Common Weal's health model here.