New breed of paramedics charged with keeping people out of hospital

Steven Morris for The Guardian 20/01/2016, gives us a viewpoint from Steve Hulks a community paramedic practitioner in Kent, whose job is about advising, reassuring – and easing pressure on A&E

You do get a rush of adrenaline,” says Steve Hulks as he activates the blue lights and siren and speeds to the first 999 call of his shift – an elderly man has fallen in his bedroom and is unable to get back on to his feet.

“But you have to be careful that the rush doesn’t distract you. You need to drive safely and think of what you need to do when you get there – how to get in, where the key may be hidden, what you may need, what may have happened to the patient. You have to stay calm.”

Hulks is one of a new breed of ambulance personnel. When he first signed up a quarter of a century ago the job entailed going to the scene of an emergency and rushing the patient to hospital. “It was about doing some first aid, putting the patient in the back of an ambulance and taking them to A&E. The problem is most people didn’t need to be in hospital – it was no good for them and no good for the hospital.”

Now as a community paramedic practitioner working on a ground-breaking scheme in the seaside town of Whitstable, Kent, the aim is just about the opposite.

He is still there to save lives but his job now is much more about helping an ageing population stay out of hospital and remain independent, advising and reassuring troubled young people, thinking about patients’ mental wellbeing as well as their physical health and working closely with GPs and other primary care providers to create a more joined-up service.

The door of 90-year-old Jack’s flat is open when Hulks arrives. Jack just about missed bashing his head on a chest of drawers when he tumbled. Carefully, Hulks checks him over before using an inflatable cushion to get him back into his wheelchair. “That’s better, that’s heaven,” Jack tells Hulks. “I don’t want to end up in hospital – that would be terrible for me. I like it here, I like my garden.”

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Over the next hour (there is no set limit to the time he spends with patients) Hulks carries out a series of tests on Jack, from his blood pressure to his eyesight. The elderly man appears confused, which could trigger a trip to hospital for head injury tests. But Hulks has visited Jack several times before and so knows he suffers from short-term memory loss. He is happy to leave him sitting in his wheelchair looking out on to his garden, knowing that a carer will arrive soon to give him lunch.

It is a good example of how the scheme works. The idea is to embed teams of highly trained paramedic practitioners into the heart of communities. They have the decision-making skills – plus the local knowledge of regular patients – to know when someone needs to be taken to hospital and when they are better off staying where they are.

Launched in Whitstable last spring and now being rolled out across other areas in Kent, the scheme has already kept scores of people out of hospital. Only a third of 999 calls handled by Hulks and his colleagues have ended in someone going to hospital; across the South East Coast ambulance service’s whole patch, the figure is around 50% – and in some trusts it is up to 70% or 80%. It is good news for patients and good for hospital emergency departments – crucial at this time of year. Other trusts across the country are watching with interest.

Today Hulks, 57, is staffing a 999 car, ready to head to urgent calls like Jack’s fall. His colleague Jess Willetts is in the GP car, carrying out home visits on behalf of the doctors’ surgery where they are based. This helps take the pressure off the hard-pressed GPs – they may be able complete six appointments at the surgery while Willetts does one home visit – and also tethers the paramedic practitioners to the patch they are covering. Meanwhile, other more conventional ambulance crews are ready to head for emergencies more likely to require hospital transfers.

Hulks’ second job of the shift is a reported assault. A young woman has been kicked in the back and had her head slammed against the steering wheel of her car, apparently by her partner. The police head off in search of the attacker while Hulks checks her over. Like Jack, she would have been taken straight to hospital a few years ago but Hulks satisfies himself that she does not need to go to A&E.

It not just her physical state Hulks considers. He talks to her about her fears and concerns. He tells her that social services may be involved. “She was upset, shaken. It’s good to give people a chance to talk. It’s often as much about mental health as physical health. We try to provide more of a holistic service.”

Another vulnerable elderly man, Pete, is the next patient to be visited, this time by Hulks and Willetts together. The 83-year-old fainted face-first into his smoked haddock at lunchtime and needs an ECG to test his heart. It saves him having to be taken to the GP surgery – good for the surgery, good for the patient.

Pete is not happy to see the paramedics. “What’s all this about? I’m fine,” he mutters. Hulks and Willetts chivvy him along. “You do the job to help people, to make a difference,” says Hulks later, “You’re journeying with someone through illness or crisis. You’re there for that moment helping, supporting.”

“Nowadays, the safest ‘pair of hands’ you can be in is most probably a paramedics – strength to all of them”

NHS ‘special measures’ has saved lives !

The NHS’s unprecedented decision to put 11 trusts intro special measures is likely to have saved hundreds of lives, experts have said. Death rates fell at the trusts after the 2013 intervention, spearheaded by NHS England’s medical director Sir Bruce Keogh in the wake of the Mid Staffordshire hospital trust scandal.

Although difficult to predict from mortality statistics, Roger Taylor, director of research at the Dr Foster Group, has published new analysis saying their had had been a fall of roughly 450 across the 11 hospitals between 2013 and June 2014.

Mr Taylor said it was almost certain hundreds of lives had been saved because of the intervention. However it was revealed  that at one trust, Tameside Hospital NHS Foundation Trust in Greater Manchester, mortality rates had continued to worsen.

Roger TaylorKey contributions include changes in management at the worst-performing hospitals, and the appointment of directors of improvement – an NHS equivalent of the “super heads” deployed at failing schools.

Tameside, Medway NHS Foundation Trust and East Lancashire Hospitals NHS Trust have all appointed new chief executives in the wake of the Keogh inspections into 14 NHS trusts that had “outlying” high mortality rates, 11 of which were subsequently placed in special measures.

Others replaced board members, and special measures hospitals were “buddied” with a successful neighbouring hospital.

New managers embarked on recruitment drives, appointing hundreds of new medical staff – a pattern repeated across the NHS following the damning Francis Report into the Mid Staffordshire NHS Foundation Hospital, where high mortality rates served as an ealy warning of problems.

Across all 11 Keogh trusts, annual mortality rates fell by 9.45 per cent after being placed in special measures. The hospitals are now closer to the average mortality rates. However, at two hospitals mortality rates remained flat and the rise at Tameside Hospital was being investigated.

A Thameside Trust spokesman said: “Initially we focused our attention on understanding and improving the care and treatment given to our patients. We now have a fully embedded mortality review process, where all deaths are comprehensively reviewed. We are now clearer on the data quality issues which require further action.”

Five Keogh trusts, including Tameside, are still in special measures following inspections by the Care Quality Commission (CQC) in recent months.

An enhanced hospital inspection and improvement regime was a key plank of the Government’s response to the Mid Staffs report. Ministers are hopeful they will be judged on patient safety, following criticism from the King’s Fund think tank, which concluded that former health secretary Andrew Lansley’s controversial flagship reforms had been “disastrous”. By contrast his successor, Jeremy Hunt, has portrayed himself as a defender of patient’s interest, the King’s Fund’s report said.

Responding to the findings, Health Minister Lord Howe said: “Since the [Mid Staffs]  scandal we have taken tough decisions to improve patient safety. Today’s report is further evidence that our special measures programme is working. Safety standards are iproving and lives are being saved.”

Andy Burnham shadow Health Secretary said: “It was because of this Government’s decision to axe thousands of nursing jobs that these hospitals were placed in special measures in the first place. The hospitals are still getting worse on key measures now, particularly A&E performance like the rest of the NHS. It is wrong and dangerously complacent for ministers to pat themselves on the back when the NHS is getting worse all over England.”

NHS hospital mortality rates are determined by two sets of figures – Hospital Standardised Mortality Rates (HSMR) and the Summary Hospital-level Mortality Indicator (SHMI). Factors that effect a patient’s survival chances include age, diagnosis and previous admissions, especially in an emergency. Analysts can determine what the expected number of deaths will be based on the national average. A hospitals HSMR and SHMI scores show how much higher or lower a hospital’s mortality rates are than the expected number of deaths.

Professor Edward Baker, CQC deputy chief inspector of hospitals said progress had be made at many of the original 11 Keogh hospitals. “We are impressed by the leadership shown in many of these trusts that has led to these measurable improvements in quality,” he said.

Cooper. C 2015. The Independent on Sunday 08/02/2015. p 2

“It’s sad really”