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Policy responses and statements
- Name of organisation:
- Scottish Ambulance Service
- Name of policy document:
- Our Future Strategy
- Deadline for response:
- 14 August 2009
Background: The Scottish Ambulance Service is currently
developing its strategy for the future, in alignment with the Scottish
Government’s
agenda for change to the NHS in Scotland, ‘Better Health, Better
Care’.
In developing its plans, the Service is keen to take into account
the views of its patients, members of the public and partners in the
delivery of health services across Scotland. The Service developed
two discussion documents, one written for its patients and the public
and another for organisations that work in partnership with the Scottish
Ambulance Service. The discussion focuses on four key areas:
- getting the right help in an emergency
- healthcare in remote and rural areas
- getting patients to and from hospital
- enhancing the care we provide
COMMENTS ON
SCOTTISH AMBULANCE SERVICE
OUR FUTURE STRATEGY
The Royal College of Physicians of Edinburgh is pleased to respond to the
Scottish Ambulance Service on its consultation document, Our Future Strategy
General Comments
There is much to be commended in this document, although it was felt by more
than one contributor that it was unnecessarily long and repetitive and would
benefit from more focus. A number of assumptions have been made throughout
the document, and while it is clear that shortcomings exist in emergency care,
remote and rural health care and transport, it is by no means generally accepted
that these would be best addressed by, or are within the remit of, the Scottish
Ambulance Service.
While the aims outlined within the document are laudable and mostly unquestionable,
there requires to be a more objective examination of where, how, and by which
agencies, these aims should be addressed. In particular, the document
fails to recognise some of the more traditional roles within emergency and
urgent care, and there is a potential for further confusion and duplication
of services unless there is a wider acknowledgement by the SAS that other individuals
and services have to be factored into, and involved in, any discussion on provision
of services.
Comments received from reviewers contained a number of common themes along
these lines. It was felt that the essential role of the general practitioner
as gatekeeper has been underestimated in these proposals, and significant concern
was raised at the suggestion that a paramedic practitioner could effectively
take on this role. The question was raised as to whether there should
be a fundamental review of the role of the GP in the out-of-hours period. It
was also questioned whether NHS24 service should continue to provide the main
out-of-hours portal.
It would be helpful if a distinction could be made between what constitutes
an unmet ‘need’, an unmet ‘demand’, and an unmet ‘want’ and
an objective examination made of exactly which of these the Scottish Ambulance
Service wish to serve.
All reviewers highlighted that a number of the developments suggested would
have significant training implications. Detail is lacking on exactly
how, and by whom, training would be delivered and what standards would apply.
It was emphasised that any new practice will require to be audited and reviewed,
given that there has been a failure to do this with a number of similar developments
in the past.
It is essential that the Scottish Ambulance Service do not lose out on their
core roles at the expense of a desire to develop new and enhanced role.
Specific Comments
Page 3 – Board Chairman’s Foreword
Page 5 – The Scottish Ambulance Service
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It has to be emphasised that the current category A target of 75% contains
no measure of quality. It would be useful if quality measures could
be developed and placed alongside this.
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It is highlighted that the demand for ambulance services is increasing
every year, but there is no appropriate consideration as to whether this
demand is appropriate and if not (almost certainly) whether measures should
be taken to curb and reverse the trend. This is surely a fundamental
process that has to be addressed. Have the Scottish Ambulance Service
considered providing negative feedback to inform individuals or agencies
that use the Scottish Ambulance Service inappropriately?
Page 6 – A Strategy for the Scottish Ambulance Service
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It is not disputed that the Scottish Ambulance Service require to establish
their role within the changing environment of the wider NHS, but it is important
that it is the correct role and that duplication of services is avoided.
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The
document fails to recognise the role of the home visit by a general practitioner
and the benefits that this may provide to avoid unnecessary transport of
patients to hospital. It was highlighted by one reviewer
that there appears to have been a subtle change from the well established
system of the emergency ambulance service supporting GPs to a system where
GPs now support the emergency ambulance service. It has to be questioned
as to whether this requires to be changed and whether planned changes would
be an improvement on existing arrangements.
Page 7 – Accessing the right help in an emergency
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The theory of the SAS and NHS24 exploring the development of a single
clinical decision support tool is sound, but significant concerns were
expressed by most reviewers. Any such system, if it is to be consistent with the
Kerr Report, Shifting the Balance of Care and HEAT 10 will have to be considerably
less risk averse than the current NHS24 algorithms. The very strong
view was expressed that medical input into this triage process is essential
with greater involvement of clinicians in point of contact, out-of-hours
primary care to assist with difficult decision-making. The default
in any triage tool must not be a “999” call with transfer of
a patient to hospital just as a way of devolving responsibility elsewhere.
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If
serious attempts are to be made to avoid unnecessary transport to hospital,
then a review of the use of local general practitioners in out-of-hours services
is necessary.
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There is clearly a downside to having a centralised triage system,
and ample evidence exists that such a central system will not have the
appropriate level of familiarity with local arrangements, so leading to
inappropriate referrals and unnecessary admissions to hospital. To
cater for differing systems in different localities, it is difficult to
argue against some form of regionalisation.
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It is absolutely essential that any new system or development
has clarity and is simple. The public are clearly confused as to
which service they should be using and how they should interface with it.
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It
was highlighted that a single assessment tool must include an option for
direct access to secondary care services such as acute medical units.
Page 9 – Delivering for Remote and Rural Health Care
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The recommendations in this section clearly depend on effective collaboration
between individuals and agencies, ranging from lay volunteers to GPs. Clear
communication lines will be essential, as will appropriate training and
skills maintenance.
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There is little or no reference to agencies such as BASICS, Scotland, which
should be included.
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The desire to extend the role of the
SAS into scheduled health care in remote and rural areas may make sense,
but this will raise issues of training and particularly skill maintenance – no
details are given on how this will be addressed.
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Community
practitioner response – this seems to be a reversal of
traditional roles and it was questioned whether the emergency services
should be supporting the GPs and nurses rather than the other way around.
Page 9 – 10
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The Scottish Ambulance Service must take great care that they do not duplicate
services that are already in place or could be better provided by other
services. The
potential for this within this strategy is significant.
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The emphasis should
be on appropriate shift of care from the hospital to general practice, rather
than the hospital to SAS.
Page 11 – 12 – Getting Patients to and from Hospital
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Of primary importance in this area is to ensure that in the acute situation
patients are not taken to hospital when that is not in their best interests,
or when their needs can be met closer to home.
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The creation of additional capacity through reduction in unnecessary attendances
at hospital is obvious, but this in itself will not be easy to achieve nor
is it necessarily going to be an inevitable consequence of a single assessment
tool unless that single assessment tool has the appropriate level of risk
assessment.
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The main need is to co-ordinate with an improved
public transport system rather than develop a new ‘dedicated transport service’. Greater
emphasis needs to be made of interfacing with social services and public
transport services.
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If there is to be development of transport services for patients with specific
needs within the limited budget available, this is likely to reduce flexibility
across all patient groups with a resultant increase in downtime of a single
resource.
Page 13 – 14 – Enhancing the Care We Provide
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It was questioned whether the national IT infrastructure is at such a level
of development that it could fulfil the needs as highlighted.
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This section
represents a significant widening of the SAS current remit. Very
careful consideration should be given as to whether the proposals in this
section would be better carried out by more established agencies. The
potential for duplication of services is again evident.
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If the Scottish Ambulance
Service were to take on these additional or enhanced care roles, this introduces
major training issues; concerns would have to be expressed as to whether
skills could be maintained.
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It is not appropriate to answer any of the questions
at the end of this section until consideration is given as to whether other
agencies are already providing this type of care or would be better placed
to do so.
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To the question ‘is there a role for paramedics in the provision
of primary care – long term condition management?’, the obvious
response would be ‘Whose role is it to supply this care at present
and why is there a perception that it is not satisfactory?’
Copies of this response are available from:
Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.
Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939
[14 August 2009]
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