Ambulance services: urgent attention for non-emergency care

Keeping non-emergency patients out of ambulances, like hospitals, has been the intention of government and managers for several years and is becoming a higher priority as investment cuts approach.

Large variations in the number of non-emergency patients being handled by the ambulance service suggest the NHS in some areas is failing to meet needs, and wasting money in the process.

Is the NHS failing to keep patients with non-emergency complaints away from costly ambulance service trips?

The ambulance service classifies patients as category C if they do not urgently require an immediate “blue light” response.

Cases include earache and sunburn, and very often older people who have fallen but are not seriously injured. A very large proportion would be better, and more cheaply, served by their GP, community services or a minor injuries unit.

HSJ has analysed the number of these incidents per 1,000 population in each primary care trust. The huge difference between PCTs suggests mixed success and sheds light on the complex factors the NHS faces in managing urgent care. For example, while there were only 6.8 category C incidents per 1,000 residents in County Durham in 2008-09, in Bournemouth and Poole there were 61.3 per 1,000.

Because of ambulance services’ differing practices, the large variation within regions may say more than nationwide differences. In the West Midlands the figure for Heart of Birmingham is 38.2, for Shropshire County it is 14.

Variation in rates of category A and category B calls, which are more likely to genuinely require an ambulance, is much lower.

Sheffield University reader in emergency medicine Suzanne Mason, an adviser to last year’s Healthcare Commission urgent care review, says: “Clearly there is something going on - there must be opportunities some PCTs are exploiting and others are not.”

For a PCT, keeping non-emergency incidents away from the ambulance service requires both commissioning of good alternative services and getting the public to access the right one instead of calling 999.

Care Quality Commission urgent care lead David Griffiths, a former ambulance service chief executive, says there is a “hugely complex and varied picture” of urgent care services in England.

Effective community services for trips and falls are an often cited missed opportunity, while good management of long term conditions can avoid calls about diabetic emergencies. Many of these patients should be dealt with by GPs, but their ability to keep patients from calling 999 or presenting at accident and emergency is varied.

Minor injuries units and urgent care centres can deal with many of the complaints involved, but patients may not understand what they offer. Addressing this problem is one of the aims behind plans for a new national three digit phone number, 111, for urgent care.

PCTs provide several explanations for high rates of category C incidents, other than alternatives being available and accessible.

They include operating in a rural area - making a prompt ambulance response more attractive to patients - and operating in an urban area with large numbers of visitors. However, daytime population figures, which include those who work in the area, do not appear to explain all of the variation.

High levels of need caused by large elderly populations and high rates of long term illness are also relevant, as are differing policy and practice.

There is the potential for flexibility in category definitions. Though intended to be quite strict, one service may allocate more incidents to category C, allowing them to be dealt with more slowly but potentially more appropriately.

NHS Bournemouth and Poole and Devon PCT say South Western Ambulance Service trust is rightly designating more away from “blue light” responses.

North East Ambulance Service trust has been piloting a system with more flexibility in triaging calls than usual. The trust says about 11 per cent of its incidents are now not met with a traditional ambulance response. But the new system may also be risk averse - designating calls away from category C and into B.

With growing use of the ambulance service and emergency departments, and associated cost, PCTs are keen to improve how immediate, non-emergency needs are met, but must do so without spending money. There are few obvious, generic solutions. New costly urgent care centres are being opened as part of GP-led health centres, but evidence suggests they often uncover previously unmet demand without moving it from elsewhere.

NHS Bournemouth and Poole was rated “best performing” in the Healthcare Commission review. Its deputy director for secondary care commissioning Caroline Dawe says: “Having a high rate is not a negative thing. It shows the ambulance service is triaging the calls effectively.”

But, she says, the PCT was continuing to improve urgent care in the downturn, by focusing on whether existing services were working correctly.

“We can’t just create more supply in the system. We have to make sure if some services aren’t being used we channel those resources back.”

David Griffiths says better integration is vital to improving urgent care without investment. Patients must go to the right place or, if they do call 999, the ambulance service must be able to refer them on.

Mr Griffiths says: “It isn’t necessarily about providing a new service, it is about opening a door to a point of referral that has previously been closed.” It is a “huge challenge”, he adds, and will require overcoming organisational boundaries.

The size of the change required may make urgent care an early target for the shifts in policy and structure being considered by the NHS as it prepares for cuts.

Devon primary care trust ambulance commissioner James Wright said: “Many people visit the area to enjoy its countryside and beaches and this presents the trust with difficulties when planning services, particularly where there are sudden dramatic or fluctuating increases in population.

“While we try to keep visitors informed about local healthcare options such as minor injuries units and out-of-hours services, some will inevitably rely on the 999 service. Devon has a much larger proportion of older people.

“South Western ambulance service is one of the best performing ambulance services nationally and employs a team of dedicated supervisors for category C calls. They aim to treat patients in the right place and at the right time by identifying the most appropriate care pathway for callers.”

An NHS Cumbria spokesman said: “There are a number of potential factors behind these figures. Cumbria is one of the most sparsely populated counties in England. The county also has a significantly ageing population. In addition, Cumbria sees an upsurge in visitors at peak times.

“Part of NHS Cumbria’s response to these geographic and demographic challenges is a programme of change which is increasingly seeing more health services delivered closer to where people live. Treatments which were previously only available from big acute hospitals are steadily being moved into local communities.”