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Saturday, September 12, 2009

Reforming the ambulance service

I have been thinking all morning about proposals by the Plaid Cymru Health Spokesperson, Helen Mary Jones to dismantle the Welsh Ambulance Service and pass responsibility instead to each of the seven new Local Health Boards. I have to say that I am still undecided as to whether it is a good idea or not and, in a way this blog post is me thinking out loud.

My first reaction to the idea was 'oh no, not another reorganisation', and it is true I think, that for Plaid Cymru in particular, the first port of call when looking for solutions to health problems is to restructure bodies. That is not necessarily a bad thing, but we do have to recognise the cost and in particular the disruption to the service, the uncertainty and loss of morale amongst staff and, to a certain extent patients, and the fact that people's eyes are taken off the ball, meaning that continuous improvement is put on the back burner. There is also a financial cost.

All of these minuses need to be weighed against the benefits and a value judgement made as to what is best for those working in the health service but, more importantly for those who rely on it for good health, namely the patients.

In the case of the ambulance service the problems are massive and are proving difficult to crack. Targets of responding to 65% of urgent calls within eight minutes are being consistently missed in some parts of Wales, especially the South East, whereas they are being met elsewhere. Rural Powys in particular is performing at unacceptable levels, whilst Gwent is not far behind them.

The reasons for this are many and cannot solely be attributed to the Ambulance Trust. In particular there seem to be problems at Accident and Emergency Departments in Gwent, where ambulances can be kept waiting for an hour or longer to deliver patients, largely as a result of a shortage of acute beds in the area. There has also been underinvestment in the service and an unacceptable requirement from the Health Minister that it improves whilst at the same time cutting £40 million from their budget of around £140 million over a two year period.

In Powys, the sparse geography of the county is a big problem, but that is exacerbated by the fact that ambulances are frequently directed into neighbouring counties to make up numbers there. As a result a critically ill patient can wait well over eight minutes for an ambulance or paramedic to arrive.

One of the reasons why the service is better in some parts of Wales than another is due to the history of the Trust. It was created by effectively stitching together separate ambulance services into one. North Wales therefore, where the service mostly hits and exceeds targets, has the advantage that the previous organisation invested in ambulances and staff with the result that there are sufficient numbers of both to cope with demand. However, despite that I understand that there were still ambulances queuing outside Ysbty Gwynedd this summer.

All of these issues contain reasons why more local control might be more beneficial. It may mean that local managers would also be responsible for meeting ambulance response time targets and that as a result blockages at the hospital end could disappear. More likely though the same problems would re-occur, simply because they are structural not managerial and need Government investment to overcome.

Local accountability may also ensure that Powys' problem of having its ambulances reassigned elsewhere could be avoided but then we would need to buy new vehicles and staff them to accomodate that. Why cannot that happen now?

In essence it seems that the main advantage of Helen Mary Jones' proposal is better co-ordination and management on a holistic basis at a local level. That in itself is not a bad thing and may well help. But whichever structure is adopted the Minister still needs to get the basics right. That means tackling the shortage of acute beds, investing in upgrading equipment and ensuring that there is enough of it and there are trained personnel to staff it, and making sure that the trust is working to realistic financial targets and is properly resourced.

Whether she can do all of that whilst at the same time conducting an expensive, time-consuming and distracting reorganisation is questionable. That is why Helen Mary Jones' proposal may be the right one in the long term but at this stage it is most probably premature.
Helen predicates her comments on the basis that bureaucracy would be reduced. The reality is that instead of 1 bureaucracy we would have 7, the controls and infrastructure would become fragmented, the level of management more junior and we would be back with all the problems that led to the creation of the Trust in the first place. Ambulance management is a specialist job and has no place in local organisations where there is no expertise in this area. Wales does not have the money to support the inefficiencies of fragmentation all that can be done once for Wales nationally should be and the scale required for the efficient and expert management of ambulance services demands this.
I agree with Patriot, it seems like it's change for changes sake!

Onto other matters concerning the Plaid health spokesperson, in the Evening Post last week, Helen Mary Jones stated that the Health Service is free at point of entry! This is simply not true, I know of at lease two individuals who have had to pay for operations that they haven't been able to get on the NHS!

Isn't it about time that we re-introduced prescription charges, people are wasting GP time and contributing heavily to the cost of the medicines budget by asking for stuff like Asprin, Paracetamol and Sanatary Napkins on free prescription?
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