A MORE flexible approach to ambulance response times might deliver better clinical outcomes for rural communities, says Brian Wilson.
Across a wide range of services – public and private – rural communities have less easy access than their urban counterparts. There can be few services where this is a more emotive issue than in the case of ambulances. To quote, "patients need to know they will get an appropriate level of service should they need to call an ambulance."
That quote comes from a report called An Involving Service, which has just been published by the Ambulance Service Network, a part of the NHS Confederation. It examines service levels in rural areas and sets out some useful practice.
Until recently ambulance targets and resources did not differentiate between rural and urban areas. The two targets set for Ambulance Trusts were: to reach 75% of life-threatening or category A emergencies within eight minutes; and to reach 95% of other serious or category B cases within nineteen minutes.
In practice, Ambulance Trusts were exceeding the category A target in urban areas, but falling short of it in rural areas. Indeed, as this report notes, rural communities often felt they were losing out and that Trusts were meeting their target by focussing more effort on easier-to-reach urban incidents.
Add to this that the NHS is being asked to make efficiency savings and that it faces growing demand. The number of ambulance 999 calls has risen by 4% each year.
Even the National Audit Office, which has overseen performance management systems, concluded the targets were skewing outcomes and not necessarily delivering the best clinical outcomes. In a report earlier this year, it welcomed moves to a broader approach.
Since April 2011 the category B target has been replaced with a more sophisticated approach which seeks clinical effectiveness and where response times are no longer the sole criteria. There are now six clinical quality indicators, which include survival rates.
This aims to promote flexibility, recognising that taking patients on a journey to hospital A&E is not always sensible. Other providers might reach an incident sooner than an ambulance and local treatment can be a better option.
The Ambulance Service Network says that this change should lead to improved services for patients in rural areas. It believes that ambulance trusts in rural areas need to develop their partnership working with other parts of the NHS, other parts of the public sector and with the voluntary sector.
One example is a 'first responder' scheme which uses community volunteers. These are trained volunteers who can respond to incidents within their own community and provide valuable treatment until an ambulance arrives on scene.
The Great Western Ambulance Service NHS Trust has developed a Public Access Defibrillators Scheme, where automated defibrillators are placed in public places so that a trained first responder can use the devise. They can, for example, be kept at a post office or a local council office. If patients can be resuscitated quickly their survival chances are significantly higher.
Closer integration with local primary care services is similarly worthwhile. The North East Ambulance Service is collaborating with a local GP in a rural part of Northumberland. There is now a community paramedic who is on duty at the GP surgery.
The report suggest that there are a wide range of potential partners for ambulance services, including district nurses, the police, dental practices, schools, the St John's Ambulance and parish councils.
There can be little doubt that some imaginative partnership working will be of particular benefit to rural communities, making both for a more efficient service and for better patient care.
It is early days to assess the impact of the revised and outcome-based ambulance service targets. In theory they should drive improvements to rural provision. It is to be hoped that someone will be monitoring that impact to see what happens in practice. For once, it may just be that an approach which better suits rural circumstances is also cheaper to provide.
This article was written by Brian Wilson whose consultancy, Brian Wilson Associates, can be contacted at This email address is being protected from spambots. You need JavaScript enabled to view it. . Brian is also the RSN Research Director.
