Should an ambulance with paramedics attend every 999 call? Patrick Butler reports from the Ambulance Service Association's conference

The swelling reputation of paramedics - they are shortly to be blessed with the ultimate in post-modern NHS quality accreditation, a television drama series - was punctured at the cruelly rational hands of the evidence-based care brigade at the Ambulance Service Association's annual conference in Harrogate two weeks ago.

Soon after health secretary Frank Dobson had fluffed the egos of those assembled - 'The public think you are wonderful because you are' - a couple of academics threatened to spoil the atmosphere by suggesting that paramedics were using potentially life-threatening methods.

Jon Nicholl, from the Sheffield School of Health and Related Research, unveiled yet to be published research which showed that patients treated by paramedics for serious bleeding injuries had a 30 per cent higher chance of dying than if they were treated by ordinary ambulance technicians.

The horror, for paramedics, of thinking patients may have died unnecessarily because they had been following flawed protocols was compounded by humiliation.

Professor Nicholl's figures showed that for most 999 interventions, technicians' outcomes were just as good as those of their paramedic colleagues.

The first piece of evidence is shocking, but will hardly bring down the profession. After all, it is not the paramedics who are at fault but the protocol that controls their actions. 'It's not who does the care but what is being done,' said Essex Ambulance trust chief executive Gron Roberts.

As Professor Nicholl pointed out, the value of paramedic care at the scene of the incident meant that if the patient survived the 999 intervention, their subsequent quality of life would be better than if they had been scooped up by a technician and taken straight to hospital.

But NHS purchasers will be interested in finding out about the relative effectiveness of paramedics and technicians.

Paramedics require expensive training and are paid more than technicians. If paramedics are only required for a tiny percentage of 999 calls, why must there be one on every ambulance?

The answer is that there doesn't need to be if ambulance services can triage 999 calls so that paramedics can be targeted at serious life-threatening incidents and not sent, as at present, to minor injuries which could be dealt with either by the non-emergency arrival of a technician or a referral to the NHS Direct helpline.

Many ambulance managers were hoping that Mr Dobson would give the go- ahead for them to be able to instruct call-takers not to automatically send a blue-light ambulance to calls that are termed 'category C' by despatch protocols - the cut fingers and chipped fingernails of urban legend.

Like his predecessor Stephen Dorrell, Mr Dobson was unenthusiastic. 'One of the big issues is what sort of response do we make to minor injuries? Something seen by the ambulance service as a minor emergency might be seen by me as a big emergency.'

It was clear, he admitted, that a lot of people did not need a 'full- blown' ambulance. It was a dilution of resources to 'take someone to the A&E department just to confirm that they do not need to go to A&E'.

But the NHS had to be 'very careful' about ending the obligation to send an ambulance to every 999 call. It would be damaging to both patient and service if it went wrong.

'I'm not saying we should not do it. But it has to be thought out very carefully and tested in pilot schemes.'

With immaculate timing, Mr Dobson was followed onto the podium by Birmingham University lecturer Matthew Cooke, who demonstrated exactly how it could go wrong when he unveiled his own soon to be published research for the NHS Executive, which showed that the protocols governing category C despatch were far from failsafe.

Dr Cooke found that 2 per cent of patients classified by control room despatchers as having minor injuries not requiring urgent treatment subsequently died in hospital. Eight per cent of this group were found to have injuries serious enough to require hospital treatment. One in 10 was an actual emergency.

Category C protocols had to be tightened up so that urgent cases did not slip through the net. Dr Cooke said he had found that, in some cases, despatchers had ignored the protocol for this reason and used 'common sense' to 'sneak people into the A&E category who should not have been'.

But it was made clear that unless ways of managing soaring demand for the 999 service were implemented - such as scrapping the historic policy of sending an ambulance to every call, and integrating NHS Direct helplines as a way of dealing with top category calls - some services would not be able to cope.

'We will not have any alternative but to find ways of managing demand. I cannot see a situation where health authorities will fund ambulance services like London at the rate that demand is going up,' said Michael Honey, chief executive of London Ambulance Service trust.

Mr Dobson's big announcement was that he wanted fire and ambulance services to look at sharing control rooms.

Unison supported it in principle but saw shortcomings. The Fire Brigades Union dismissed it as 'completely flawed'. Ambulance managers welcomed it as 'common sense'.

But it was clear that category C was uppermost in their minds. It was not the big announcement they had wanted to hear.