‘This Job Is Tougher Than I Thought It Would Be’

Ambulances held together with sticky tape, fire engines taking critically ill patients to hospital and a patient dead after calling 999 eight times for an ambulance. This is not the type of service any one of us would expect from an ambulance service in the developed world.

Yet these are just a snapshot of the problems which the Welsh Ambulance Service has experienced in the three short months since the beginning of the year.

Add to that the latest response time figures, which reveal the service has still not met the rather generous target of responding to 60% of life-or-death emergencies in eight minutes – the target is 75% in England – and two damning reports from the Auditor General for Wales and Healthcare Inspectorate Wales, which essentially said lives are being lost because of the service’s failings, and it is clear the Welsh Ambulance Service is in trouble.

To be fair to Alan Murray, who took over as chief executive in August – the seventh in just 18 months – some of the ambulance service’s problems are historical and stem from almost a decade of mismanagement and consistent waste of public resources, or are a symptom of the wider problems facing the health service as a whole.

But the current, and much publicised, recent adverse events in the service’s turbulent history – including ambulances not arriving on time and the poor physical state of ambulances – speak more of a service in crisis than one that is slowly being turned around.

And yet Mr Murray is confident that the Welsh Ambulance Service has turned a corner and is beginning to improve. He is on record as saying the service will meet the 60% response time target during 2007/08 – staff are being “educated” that the targets are clinically meaningful and not just another governmental hoop through which they must jump – and he believes the modernisation plan, Time to Make a Difference, has all the right ingredients to restore public confidence in the service.

He is also committed to seeing the job through, telling the Western Mail, “I have given my commitment to the chair [of the Welsh Ambulance Services NHS Trust] to stick it out to the end. I believe this is more likely to be a five-year programme, than three, but that doesn’t mean that we will have to wait five years to deliver clinical effectiveness. This is not just about recovery, it is about modernisation. This job is tougher than I thought it would be – but there is absolutely no wavering in my belief that the service can be turned around.”

Perhaps one of the first, visible, green shoots of revival has been the success of the GP triage system, which was put in place in three control rooms in South Wales at the start of the month.

The scheme was set up because the service had been able to forecast – for the first time – that as many as 1,500 ambulances would be delayed at hospital for more than 50 minutes during March.

For the past two weeks GPs have been helping to assess whether 999 callers really do need an ambulance, or whether they would be better served by contacting another part of the NHS. They are also helping paramedics on the scene to decide whether a patient needs to go to hospital. The system was put in place for March only – funding runs out at the end of the month – but has already freed up ambulances.

Mr Murray said, “A lot of people use 999 because they find the NHS too complicated to handle. Callers use 999 inappropriately and we have been ignoring that for years.”

The latest figures show that ambulance delays of 50 minutes or more at hospitals – a symptom of the wider and growing bed blocking crisis in Wales – have fallen to an average of 28. By comparison, in South East Wales alone, on February 12, there were 99.

“This has a lot to do with the action that we are taking with our partners in the healthcare system and down to the effect of having GPs in control centres,” Mr Murray said. But 28 is still too many and we have to work together to get that down still further.”

Another visible sign of regeneration within the ambulance service has been the delivery of the first of a new fleet of ambulances equipped for the task in hand, unlike the last procurement process in 2002 when £2m was wasted because the ambulances were later found to be too heavy to drive.

The ambulance service has received £16m for the new ambulances from the Welsh Assembly Government and a further £55m for new communications equipment, which will eventually be able to pinpoint ambulances and quickly dispatch calls, speeding up response times.

But, despite seeing the sorry state of the ambulance fleet first-hand, Mr Murray said the new vehicles alone are not the solution. “The model is giving people the tools to do the job and the new ambulances will make a significant improvement in that area,” he said.

“I recently did part of a shift with a crew in Cardiff who are working with a seven-year-old ambulance. I told them this was unacceptable and the paramedic held up a mobile phone with a picture of an ambulance which was held together with sticky tape – albeit strong sticky tape – which is unacceptable.

“The new ambulances are not the solution, but getting rid of every ambulance over five years old will make a huge contribution to the reliability and ensure that there is an ambulance there when a crew comes on duty.”

Despite Mr Murray’s optimism about the ambulance service, he admits that it still faces a number of challenges on its rocky road to recovery – not least technology.

He said, “One thing we had in our favour in Merseyside was that there had been investment in technology – the technology here is patchy. We have decent computer-aided dispatch systems but it has to be a network. The new ambulances have satellite navigation, but until we get the digital radio system in, we won’t have a carrier for that. We are waiting for Tetra and when we get that, when a call comes in it will automatically put the location into the satellite navigation.

“We have to streamline every aspect of our call handling from how long it takes to pick up a call and how long it takes to verify the location – for example, verifying that a call comes from the right Station Street in Cwmbran, not one of the other five. We want to be able to do this in 95% of cases within 30 seconds or less, but we can’t do that without technology.

“We also have to keep the staff on board – so far they have demonstrated great goodwill and flexibility, but we have to ensure that we handle the change sensitively, and part of that is reminding ourselves what we are here for. I ask every group of staff I meet, ‘Hands up who got into the service to meet Welsh Assembly Government [response] targets?” and no one puts their hand up.

“But the important thing about these targets is understanding their relationship with good clinical outcomes – if the first shock is administered to a patient in cardiac arrest, there is a 43% chance they will leave hospital. It is a similar story for major trauma.

“But we also have to change the attitude in the ambulance that says if you reach a call within eight minutes and one second and the patient lives that’s a failure, but if you reach them in seven minutes and 59 seconds and they die, that’s a success. I have no doubt that we can hit the response time targets and maintain them, but there will be some drops in the early days.”

Perhaps the biggest challenge – and the biggest opportunities for the ambulance service – will come when the Assembly Government finally publishes its completed Delivering Emergency Care Services (Decs) plan, which details how all emergency and unscheduled care will be provided in Wales and will examine the role played by all parts of the NHS.

It is hoped that Decs will open up new ways of allowing people to contact the NHS, especially out of hours, without dialling 999 and open up new roles and responsibilities for the ambulance service, beyond that of an emergency transportation service.

But at heart Mr Murray wants to create a modern and efficient ambulance service that the people of Wales can believe in and that its employees are proud to work for. “People are working hard to change things and they are seeing these changes starting to take effect. But every time they open a newspaper or switch on a television they see the service being slated, which has an effect on morale.

“Last week technicians told me that they were reluctant to say that they worked for the ambulance service – why would someone who does an excellent job say that? We are turning the corner and I want the staff to be proud to work for the Welsh Ambulance Service NHS Trust, and I see no reason why they shouldn’t be.”