A target too far for Scotland's overstretched paramedics

The relocation of key NHS services and changes to the provision of out-of-hours care have massively increased demand, the Scottish Ambulance Service (SAS) said yesterday.

Despite this, the service is moving closer to meeting a target of responding to 75 per cent of life-threatening emergencies within eight minutes.

Paramedics, technicians and call handlers have now expressed concern about the growing pressures they face to meet the target.

In 2002, a system of prioritising 999 ambulance calls started to roll out across Scotland. Rather than responding on a "first come, first served" basis, calls are categorised A, B and C.

Category A calls – life-threatening emergencies – have a response target of eight minutes.

Category B covers serious but not life-threatening incidents, with a response target of between 14 and 21 minutes depending on whether the area is urban or rural.

Category C calls are non-serious calls, which may often be referred to NHS 24 to deal with.

The latest results show that 62.9 per cent of Category A calls are attended to within eight minutes across Scotland, against a target of 64 per cent.

But the bar is moving higher and from April 2009, the service will have to be able to respond to 75 per cent of top priority calls within eight minutes.

Nobody predicted the huge rise in demand the service would experience following changes to out-of-hours care, which appears to have led to more people calling 999, and also after the reorganisation of services, which means some patients have to be transported further away. An SAS spokesman said: "We have had to deal with a great increase in demand as a result of changes in out-of-hours provision.

"A lot has changed in the context of the NHS since the targets were originally set, not just with out-of-hours but also with changes to the availability of hospital services. But our focus is on achieving our targets. The focus throughout the service is on achieving the targets."

The spokesman said that when planning to meet the 75 per cent target – before it was introduced – officials predicted that it would be necessary to deal with 63,000 life-threatening call-outs a year by now.

In fact, the number of call-outs so far stands at 91,000.

"While we are still working towards that 75 per cent figure, given the level of demand and the changes to the provision of health services we have seen since the target was set, the position we are in now is still quite impressive," the spokesman added.

A spokesman for the Scottish Government said: "This is an achievable, clinically founded target that recognises the fact that for people suffering cardiac problems eight minutes is the period of time in which you have the best chance of making a difference."

The government spokesman went on: "In an emergency situation patients rightly expect our health services to give them the best chance of survival, and we are working with SAS to make sure they deliver."

Crews tell of frustration at emphasis on call-out times

THE small screen on Charlie Wishart's dashboard lights up, beeping an urgent appeal for help. A 59-year-old woman is suffering from chest pains and her husband has called 999.

Mr Wishart quickly alters the course of his rapid-response vehicle, blue lights flashing and siren on, as he races from the centre of Edinburgh to East Craigs in the north-west of the city. It is 4:50am and the roads are quiet, only a handful of cars pulling over as the emergency vehicle seeks out its patient.

By the time the paramedic pulls up in front of the school caretaker's house, nine minutes have passed since the call for assistance came in.

Mr Wishart gets his medical kit and heads into the bungalow, finding the patient struggling for breath in bed. He checks her over, takes her blood pressure, reassures her she is not wasting his time by calling and tells her it is best she goes to hospital. By this point, an ambulance has arrived. The crew quickly gathers her medication and carries her outside for the trip to Edinburgh Royal Infirmary.

This is classed as a failure – at least according to official Scottish Government targets. The target states that an ambulance team should arrive at emergency calls – known as Category A – in fewer than eight minutes. There is no leeway. Missing the target by only one second is judged a failure. It is a pressure felt across the Scottish Ambulance Service, from senior managers to call handlers.

But nowhere is the pressure more acutely obvious than among the paramedics and ambulance technicians on the front line. And it is clear there is growing disquiet over a target that classes many of their greatest saves as disappointing misses. "It seems they are more interested in getting the vehicle there on time than they are about what we do when we get there," Mr Wishart, says as he patrols Edinburgh on one of the year's busiest nights for the service as Christmas revellers flock to pubs and clubs.

"You could have a situation where you get to a patient in under eight minutes but they die of heart failure, and this is classed as a success. But if you arrive on the scene in eight minutes ten seconds, for example, and you save the life of someone who has suffered a heart attack, this is seen as a failure."

Back at the ambulance station, he is not alone in feeling the injustice of what is seen by many as an arbitrary target. The ambulance crews talk about delivering babies, saving children with asthma attacks, helping the victims of road accidents – many of them failures as measured by the eight-minute target.

"Crews are putting their own lives at risk by driving faster to reach these jobs on time," Mr Wishart says. "When Nicola Sturgeon (the health secretary] came to open the new ambulance station, I wanted to ask about where this target came from, who set it, why they decided on eight minutes. But I did not get the chance."

HE GOES on: "It has been set at eight minutes for years, with no adjustment for the greater volumes of traffic on the road, the increase in speed bumps, the growing number of people calling the ambulance service. It is something all ambulance staff feel frustration about and would like to see more emphasis on outcomes rather than a simple measurement of time."

Mr Wishart has held various roles in the ambulance service in Edinburgh in the past 20 years, previously working as a bus driver and RAF police officer. He has two young children and a wife at home, and the 46-year-old says that, while he enjoys his job, his main priority is getting home safely after every shift. With attacks on NHS staff continuing, it is not difficult to understand why he feels this way.

Two of his brothers are serving in Afghanistan – clearly a source of much pride for him and the rest of his family. But back in Edinburgh, Mr Wishart is fighting very different battles – against the damage alcohol does on the streets, heavy traffic and, of course, government targets.

In the early hours of Saturday morning, meeting targets is an even greater challenge, as the results of Scotland's binge-drinking culture take full effect.

His shift starts at 6pm on Friday, finishing at 6am on Saturday. He drives a rapid-response vehicle – a one-man operation that aims to get to patients quicker. He can then either treat and discharge them himself, or provide help before an ambulance crew arrives to take the patient to hospital.

DURING his 12-hour shift, he sees 16 patients, 11 of them suffering the effects of alcohol. One such call comes in at 10:45pm – a drunk woman has fallen into the side of a bus as it pulled up at its stop. Mr Wishart crouches down next to the woman, who is wailing as if in terrible agony as bemused passengers on the bus look on wondering if they will ever get home. The woman's boyfriend stands nearby, lighting a cigarette and watching, disinterested, as the pavement drama unfolds. Two patrolling police officers join in trying to find out what is wrong, but the woman appears unable to say where she is injured. An ambulance crew turns up and says she will have to go to hospital. But suddenly she jumps up, yelling at the crews: "I just wanna go home!" One of the police officers quips, "That has to be the most miraculous recovery since Lazarus", and the crews leave, in search of those in greater need.

At 11:30pm, there is another call to a drunk, this time in the Grassmarket. Some good Samaritans have come to the aid of a young, floppy-haired student, slumped on the floor and vomiting in all directions. "Everyone was just walking around him," one said. "He really doesn't look very good." He is sickly pale, can hardly utter his name and standing up is beyond him. This time, the ambulance crew does take him to hospital.

A similar theme continues throughout the night: three drunk sisters who have had a row, one kicking another in the head; a drunk man who has fallen and cracked his head on a cobbled street; a man unconscious outside a supermarket.

As Mr Wishart heads back to the ambulance station for a break at 1:05am – they get only 45 minutes during a 12-hour shift – he spots another young man slumped in a bus shelter in the Pleasance, a bottle of whisky beside him.

THE man, who turns out to be Polish, responds only to the most vigorous shaking. As temperatures plummet, he cannot be left alone on the street. A police van arrives and one of the officers examines the contents of a plastic bag laying beside him – a bottle of brown sauce and two of ketchup. "I know what's happened here," he says. "He's just been out on the sauce." The officer than tips the contents of the whisky bottle away before the now semi-unconscious man is helped into an ambulance.

Mr Wishart is philosophical about the endless stream of drunks. "Sometimes, you do get sick of it, but you have to remember that, just because someone is drunk, it does not mean something bad could not happen to them if you just turned away," he says.

He is modest about his job "I'm just a blue-light taxi man in a green suit," he says as the next call to an unconscious reveller comes in … a new target to be met. As the service faces another busy week in the party season, it is clear the blue-light taxi drivers have never had it so tough.

999 CALLS SOAR OVER FESTIVE PERIOD

CHRISTMAS and New Year are the busiest times for the Scottish Ambulance Service.

The average number of 999 calls the service receives during most months of the year is 32,361.

But last December, this went up by 14 per cent, meaning they were dealing with an extra 4,562 calls in the month – or 147 a day.

New Year is even more challenging, with calls in January up 17 per cent – an extra 5,585 calls in the month or 180 a day.

The majority of the additional work is related to drink or drugs.

Between 6:45pm last Friday and 6:45am on the Saturday, the number of 999 calls dealt with by crews in the Lothian area alone was 135.

The average response time to life-threatening calls – Category A – is 8.3 minutes.

This response time includes some of the most remote areas of the country, in which ambulance crews cover large rural areas.

As well as dealing with emergency calls, the ambulance service also handles less urgent appeals for help, including transporting patients to and from hospital.

The service employs about 3,200 staff including paramedics, ambulance technicians and call handlers.

An experienced paramedic can earn about 32,000 a year, including an unsocial hours allowance. Technicians, who carry out a similar role but do not have the ability to administer as many treatments, are paid less.