I welcome our witnesses.
Highland Health Board is in the upper range of performance, therefore we are relatively satisfied with the ambulance service's responses. However, I recognise that my colleagues may have a different slant on that.
By and large, Tayside Health Board comes out reasonably well in the report. Obviously, there are differences between response times in urban and rural areas that must be taken into account when one examines the figures. Members will be aware that Tayside has a range of urban and rural locations. Rural areas may have only a single ambulance so, although the ambulance service will always send the nearest available vehicle, one must accept that there will be delays.
There are several paradoxes, one of which is that while missing target times by a minute or two may not seem a lot—the difficulty of judging the clinical impact of such a delay will come out in our evidence—it is an awful long time for the patient or relative who is waiting for an ambulance to arrive. The answer to the question "Are we satisfied?", therefore, is no. How can we be satisfied if well-established targets are not being met?
What are the consequences of missed targets? Could lives be at risk?
That is difficult to say. In 1998, we did a survey of one week's attendances at all accident and emergency departments in Glasgow. In that week, there were something like 4,580 attendances at A and E departments, of which about one third arrived by ambulance. Of those 4,580 attendances, 11 patients died in A and E departments. From the data, we do not know how many patients died subsequently in hospital for reasons that may or may not be attributable to ambulance delays, or how many would have died without entering the A and E department. My clinical colleagues will be able to say something later about the state in which patients arrive in the department. The data are lacking.
It is difficult to say whether patients would die. The standards are set arbitrarily, and are standards to aim for. Anecdotal evidence that I have heard suggests that we make very good responses and that patients would not come to harm or die if standards slipped slightly, which is inevitable at times of peak demand. The die is cast, if you like. Missing the standards by the times that we tend to miss them by will not make a great deal of difference.
Is it true that no data are collected? How difficult would it be to collect such information?
It would be very difficult and an element of subjectivity would be involved. Deaths within the hospital are all recorded, but the committee must bear in mind that death may be pronounced in the hospital in cases when the patient died at home but attempts at resuscitation continued until the patient reached hospital, where death was declared. On very few occasions can the ambulance crews say that someone is dead and take him or her to a mortuary.
The other difficulty is linkage of records. I am not familiar with the detail of the Scottish Ambulance Service's record-keeping systems, but they tend to be paper-driven. The crew files a report after it has taken the patient to A and E. On some occasions those reports are done contemporaneously, while on others there is a slight delay because the ambulance has to respond to another call.
So is it more of an information technology problem than a clinical problem?
It is a bit of both. We would also need to get consistency of definition right.
The evidence on ambulance response time targets shows that the service's performance has not improved greatly in recent years, while the performance of the least responsive division has worsened. What is your assessment of the wide gap in the service's performance between different parts of Scotland, and between different stations that operate within the same health board area?
The rural nature of the Highland Health Board area has a major impact on the response times that crews are able to achieve. For example, ambulances in Inverness may respond to a major trauma in Inverness and reach Raigmore hospital, also in Inverness, in a matter of minutes. However, a patient may require an A and E response from the village of Bettyhill, in the far north of Scotland, where the road infrastructure and weather conditions can mean that it sometimes takes three and a half hours for the patient to reach Inverness from the point of uplift. We have other A and E units, but Raigmore is used in cases of major trauma.
The report points out that, in the past five years, there has been a 28 per cent increase in the number of 999 calls; I cannot speculate on the reasons for that. In Tayside, the ambulance service has been able to absorb that increase through greater efficiency.
How can you square such performance gaps with the overall goal of providing equality of access for national health service patients throughout Scotland?
The report highlights the fact that the ambulance service staffs at average demand. We might all want to staff at peak demand, but the reality is that we cannot afford to do so. Occasions will arise on which there will be delays, but I understand that the ambulance service will send the nearest vehicle to the incident. That vehicle will respond immediately, but there may be some delay: in an urban area, vehicles are normally available, but in a rural area a vehicle may have to come from further afield.
The issue is one of equity of access. It would not be possible to have a single measure; urban-rural differences would make that impractical. I can speak only for the service in an urban environment, but we should expect that whatever criterion is established nationally—50 per cent within seven minutes or 50 per cent within eight minutes—that standard should be met in Scotland's towns and cities. That seems to be a reasonable aspiration.
More support may be received from a local general practitioner in a rural area than in an urban situation. Dr Morrison may want to comment on that. For instance, when a patient in an urban situation suffers a myocardial infarction, the priority is to get them to hospital as quickly as possible. In a rural situation, support may be provided by the local GP, who can begin treatment sooner. It is not a case of one size fits all.
The ambulance service in my area makes good use of resources. If an ambulance in a rural area is off station, an urban vehicle will cover for it and vice versa. That leaves gaps at times, but is a reasonable way to do things, and it is the best that can be done in the circumstances.
Before I invite my colleagues to ask questions, I have one further question. The quality and efficiency of the ambulance service is crucial to your work in health boards and trusts. What contact, therefore, do you have with the Scottish Ambulance Service and what priority do you give to including that service in planning?
The involvement of the ambulance service is seen as fundamental in the Highland Council area, because—as a result of sparsity—it plays such an important part in the provision of care in the community. We had a good relationship with the service during the internal market period, as we have in the new health service. The ambulance service is involved in our health improvement programme planning process. It has adopted that programme this year and it has been consulting the health board while it plans its programme.
We have a similar relationship with the ambulance service and we have a member of staff who liaises between the health board and the ambulance service. On planning, we are in the middle of an important acute services review and a group is examining transport issues as part of that review; the ambulance service is a key member of that group.
Our experience is that over the years there has been a lot of contact between middle-ranking people in Greater Glasgow Health Board and people in the ambulance service divisional headquarters in Glasgow. More senior contact has not been common until recently. In the mid-1990s contact was the result of contract negotiations, but the important bigger picture probably was not seen. With the recent change in divisional management arrangements there is now greater prospect of the contact at senior level that is needed.
The survey that was done in Glasgow is interesting; I note that it was based on accident and emergency data and not particularly on ambulance service data. Are you aware of any work that has been done by health authorities and the ambulance service on whether response times have any effect on outcome?
No.
There are a number of areas in which there is scope for significant meaningful research, and a research agenda is unfolding from today's discussion. That research is necessary before decisions can be made about the most effective way in which to manage the service in the future.
So can you see an opportunity for a series of collaborative clinical audit projects?
Yes.
On an operational level, we have regular communication with the ambulance service. We interface with the paramedics and technicians and with the divisional officers. Those links are important, and I would like them to be much closer. It has always struck me as slightly strange that ambulance depots are not situated in or next to hospitals, but tend to be quite distant from them. I am not sure why that is the case. In the American system, emergency vehicles operate out of hospitals or emergency departments, which has many advantages. It certainly makes communication a lot easier. At the moment we are conducting a study on the passage of information between the pre-hospital and hospital arenas. We have found that neither we nor the ambulance crews are happy with the situation. The hand-over is always one of the most difficult parts of a patient's journey, because it involves getting information across to hospital staff.
We have already touched on the rural-urban divide. In paragraph 2.9 of page 27 we are told that the average response time for a 999 call in a sparsely populated remote area is 20 minutes, compared with 10 minutes elsewhere. Obviously, there are resource constraints, but what else do you think the service could do to encourage equality? Mr Spry used the word "equity", but this is an issue of fairness. What can be done to achieve equality of access for patients who live in sparsely populated areas? Does not that require lateral thinking?
An aspect of equality that we have not yet addressed this afternoon is clinical need. There will be cases in which it will not matter whether there is a delay in an ambulance attending. In such cases, we might question whether an ambulance is the appropriate intervention. There are two issues here: the so-called priority dispatch of crews and vehicles, and the need to consider other kinds of intervention to deal with some types of emergency call.
You have given us examples of other kinds of intervention. Other suggestions have also been made to us, some of which would have implications for the health board. How would you feel about people who are employed in other sectors of the health service in remote or rural areas doubling up or working part-time? That might allow additional cover. Are traditional ambulances always required, and do we need ambulances based in formal ambulance stations?
In the Highland Council area we are already fairly flexible in our deployment of ambulances. Some of the stations or bases that are mentioned in the report are the residences of ambulance service staff. That is because in some of the communities from which they must operate there are no suitable premises. The report makes it clear, from the perspective of the Scottish Ambulance Service as well as that of the health service, that there is scope to explore how trained and valuable personnel, such as paramedics, could be used better in the community. Likewise, at the other end of the scale, one might—as Mr Adam suggests—consider how to use resources that are already in the community.
I would like to make a point that relates more to a previous question. I am not sure whether the report highlights this, but there is an urgent category of patient who would also be moved by 999 vehicles if the family doctor saw them at home and wanted to have them admitted to hospital. The general practitioner will normally advise the ambulance service that he or she would like the patient to be in hospital in one hour, two hours or four hours. That is an example of another independent doctor saying what the priorities should be. There are concerns, however—sometimes the target time is not met. At least the ambulance service can go back to the doctor and say, "We can't make in two hours—can you wait another hour?" There can then be a dialogue about the priority, which, for most other calls, does not exist.
There is some difficulty regarding the skills that are required. I understand what is being suggested, and it is a good idea. We have been considering a tiered emergency service with units—or whatever you wish to call them—in more rural areas. I am thinking along the lines of minor injuries units that could be based in cottage hospitals and, possibly, run by nurses. It would make sense for such units to be adaptable so that they could be used in the most appropriate way.
I would like to reinforce the point about multi-skilling. The example that I am most familiar with relates to nurses, not to paramedics. A difficulty in the remoter parts of the Highland Council area is that the work load is not sufficient to maintain the critical skills of nurses who are trying to act as district nurses, midwives and practice nurses. So-called triple-duty nurses are becoming a thing of the past, simply because the work load is not sufficient for them to maintain their expertise. That is a serious issue when it comes to paramedics.
Paragraph 2.23 on page 34 of the NAO report explains how the response time targets were set some 25 years ago. Those targets for 999 calls are based not on clinical need, but on a first-come-first-served basis. In the times that we now live in, is that acceptable? Should we review the way in which we measure the performance of the service?
We all agree that there is no clear evidence at the moment on which to make such a decision. Logically, one could argue that targets for dispatch that were based on an assessment of need would be more effective and efficient, but we are aware of no research evidence to support that. However, as I think your question suggests, there must be some unfortunate individuals who are receiving less efficient care than they should because of the current dispatch system.
In our case, as demonstrated by a survey conducted in Glasgow, about 60 per cent of patients—quite a large number—who arrive at accident and emergency in a 999 ambulance are referred for admission to hospital and should be considered to be seriously ill.
There is no evidence one way or the other, as the matter has not been investigated in sufficient detail. Any changes must be compared with the system that is in place. On the face of it, it seems entirely sensible that a priority-based service is better than a first-come-first-served service. That seems so evident that it is not worth commenting on.
Figure 9, on page 29, is one of the most interesting graphs in the report. That graph illustrates the profile of response times for Glasgow central ambulance station alongside the profile for Dundee ambulance station. Several interesting and important issues arise from that graph. First, we do not know what caused response times of 17 and 18 minutes or more, but it is pretty unacceptable by any standard for people to wait that long when one does not know what is wrong with them. Secondly, if one concentrates on the seven-minute standard, one should examine how many patients fall just outside that standard, because many do.
We will now consider deployment priorities.
I would like to follow up on some of the comments that have been made. A number of witnesses have commented on the pros and cons of priority dispatch, on which it is quite clear that there are different views—we would expect that.
In a way, there is a priority dispatch system. A general practitioner—especially one in an urban area—who receives a call from a patient who describes the symptoms of a heart attack or myocardial infarction, will tell that patient to call 999 immediately. The patient will be taken to the accident and emergency department. There is unquestionable medical evidence that if that patient receives thrombolytic or clot-busting drugs early, the heart attack's symptoms can be reversed almost entirely. Although that might not be called priority dispatch, the system ensures that the person gets to hospital rapidly. Also, the message is getting across to patients that they should dial 999 at the first sign of the symptoms of heart attack. There are proven medical benefits of the early treatment of certain conditions.
Page 39 of the report shows that, in a survey of clinicians and others concerned with the emergency ambulance service, more than 90 per cent supported the concept of priority dispatch. Most respondents also favoured varying response-time targets to reflect patients' varying needs. Does that mean that there is a need for consultation with patients and other health care partners in framing any proposals to move to a system of call prioritisation? Would that system give rise to any insuperable moral considerations?
It seems obvious that priority dispatch is the way to go. The question must be what the correct form for that is. I do not pretend to know what that would be—we do not have sufficient data. We need to discuss the correct form with various agencies, general practitioners and patient groups. It is not for me to force my opinion on anyone.
I would welcome your opinion as a clinician.
There must be brief questioning to ascertain symptoms; that cannot be done by an untrained person. However, NHS Direct is an out-of-hours telephone advice and information service in which nurses ask and answer questions and decide what course of action the caller should take—that might serve as a model. The questioning session should not be long and should not be stressful for the patient.
I have not yet seen an evaluation of the English experience of criteria-based dispatch. However, I have talked to accident and emergency consultants in Glasgow about the issue—they support the principle of criteria-based dispatch and are extremely thoughtful about the practicalities. Their reading of the English experience is that there is significant under-detection of critical illness. What is meant by significant? I do not know—I have not seen the data. However, there is concern, which means that questions must be pitched carefully, and care should be taken over the ways in which questions are connected to the protocols for action that the dispatcher then pursues in dealing with the call.
Is the obverse of that, that if we fail to adopt the priority-based dispatch system, another moral consideration lurks, which is that lives might be being lost through abuse of the ambulance service?
Probably. The problem is that we do not know. It is, perhaps, more for Dr Morrison to say, but when somebody dies, it is difficult to determine whether they might have survived if somebody had got to them five minutes earlier. Dr Morrison and I discussed this on the way here. As others have said, given that we are prioritising in all other aspects of medicine, it is logical that we should be trying to do it in this matter, too. Like Chris Spry, I would like to see results from places where such a system has already been in operation, such as parts of England.
I am afraid that I am getting anecdotal here, but part of the difficulty is that abuse of the 999 system is sometimes associated with people drinking or being on drugs. It might be obvious to whoever is receiving the call that the person on the other end is under the influence of drink or drugs, but that does not necessarily mean that there is not an issue that needs to be addressed. In fact, it becomes more difficult to work out whether the call really is urgent. It becomes even more difficult at times when more people are likely to be under the influence of drink. Friday and Saturday nights, for example, are when priority-based dispatch is most needed, yet that is when it would probably be difficult to handle with the confidence that we would like.
My comment relates to Miss Goldie's question. The users of the service have, if you like, voted by their views, however scientifically those views were taken.
In answer to your question—and I am afraid that any evidence would have to be anecdotal—people have died through abuse of the 999 system: there is no doubt about that whatever. The issue of drink and drugs is an important one that will not go away, but will cause difficulties. It causes me difficulties on Friday and Saturday nights as well. I do not presume, just because somebody comes into the department intoxicated or on drugs, that that is their problem. That must be taken into consideration; it is not easy, but we must work round it.
Is it possible for you to quantify your anecdotal statement that people have died through abuse of the system? Are you talking about a large or small number of people? Can you give us even a rough figure?
That would reduce the issue to my personal experience. I know of cases in which people have died. I also know of someone who dialled 999 because they took the head off a plook while they were shaving in the morning. There is evidence that the best thing for patients who have a cardiac arrest is electricity—defibrillation—which must be provided quickly. If an ambulance is tied up attending someone who has a minor problem, it will not attend the person who requires resuscitation.
No, you could not.
I could not give any names, obviously. However, that is my perception of the situation.
The evidence that we heard from Mr Spry, of cases in Glasgow, was interesting. I was not surprised by the figures for 999 calls that he quoted for the Southern General, given its reputation for dealing with head injuries. I might be making an assumption that is not right, but I imagine that quite a large number of cases at that emergency unit would come from 999 calls.
I would guess that we need to start where the response will have an evidence-based outcome. That is easy for me to say, as I am not the clinician. We are trying to design a health service that is evidence based and patient centred, and two or three issues need to be pulled together. We must look for evidence, and research must be undertaken. People such as Dr Morrison can inform that process.
Which areas do the clinicians think that we should manage with greatest care?
There is some evidence from pilots in certain areas of England, but there is very little. That must be the starting point. It is all very well for us to say that there is no evidence; somebody must find it. It may as well be from a group from our country. We should get together with the ambulance service to consider the best way of instituting a system, perhaps on a trial basis in a limited area, so that we can see how it could be developed.
That is the starting point. Quite a few systems are in operation around the world, including some in England. Most, if not all, of them will have undergone some sort of evaluation. I would start by examining what is already in operation and seeing what the evaluation of the system tells us. Either the system will be acceptable or, if it is not, we can consider how to build on the best to take art and science forward in the interests of Scotland.
I note that you say that you would start by examining the systems. I take it that no one is doing that yet.
I would assume that the systems are being evaluated. When the committee sees the ambulance service next week, I imagine that it will have more information. I want to raise one small point. The system will probably not work in rural areas where there is only a single vehicle, so the system will not be universally applicable.
A number of points have been well made, but I want to draw things together. Page 38 of the report says that
That is a difficult question, but I know that we are here to provide some answers. The Scottish Ambulance Service is now its own special health board. As director of Highland Health Board, I would expect it to find its own resources, but I doubt that the chief executive of the national health service would thank me for saying that.
One of the issues for me—this goes back to Miss Goldie's comment about moral problems—is the need to be convinced and to be able to demonstrate to the public that what is proposed is better than what exists. I am therefore in favour of a pilot of the system or action research. If we are convinced that it will be better, the most efficient way to resource it might be to tackle it as a national initiative.
Highland Health Board, therefore, does not have a policy for or against the system.
I would not expect an individual health board to have a policy on the matter. Either the system is put in place for the whole country or it is not. You cannot have priority-based dispatch in place A and not in place B. The country needs to decide.
I echo what Mr Spry said. Such a system would have to be considered alongside a range of other options and priorities. Off the top of my head, I reckon that it would cost £3 million plus to introduce a priority dispatch system for the whole country. I have no doubt that the ambulance service would say that some of the other problems in the report could be solved with that sort of money. However, the principle behind the response should be the same as in all other areas of health care, that one gets to the person in greatest need first if possible.
I take Mr Spry's point—it is a national rather than a health board problem. However, who should be initiating the studies or insisting that this is a priority?
It is a matter for the Scottish Ambulance Service board in discussion with the NHS management executive. Health board general managers could comment if invited to do so.
It would be a significant decision, in which a minister would want to be involved.
Who made the decision in England?
I am pretty sure that there was ministerial approval to pilot the system.
If we are talking about a possible national policy change, is there a case for piloting it in urban areas?
Yes.
As far as I am aware, the decision was taken some time ago that this was the way to go. When I first arrived in Tayside, six or seven years ago, I was told by the ambulance service that it would be introducing a priority-based dispatch system in two years' time. That is the intention, but it has not happened yet.
If there is an urban pilot, it should include a rural area because, as Tim Brett said, priority dispatch might not be an issue in an area with only one ambulance. I support the idea of a pilot, but rural areas should be taken into account.
We should now concentrate on Glasgow.
Section 2.11, on page 27 of the report, indicates that the response times for 999 calls in Glasgow are very poor compared with similarly populated areas in England. What has the service been doing to alleviate that difficulty?
It has been doing a range of things. There has been a review of rosters, as one often finds that response times are poor because the rostering pattern does not match the demand pattern. There have also been attempts to tackle sickness levels, as high sickness levels blow a hole in rostering. At one point, we funded an additional ambulance on the south side, after we came to the conclusion that the only way of improving the situation was to put another vehicle on the road.
How do you track that? We have heard today that there is no evidence to support the information, but we have been told by those working in the service that it can take 90 minutes to transfer a patient because the patient is not at the door of the acute hospital. Has Greater Glasgow Health Board made any attempt to evaluate that?
That is why discussions between senior ambulance managers and trust chief executives are so important. What you describe is a readily recognised problem—an arrangement is made for a patient to be transferred, but when the crew arrives, the patient is not there. It is depressing how often that happens. High-level intervention is required in the trust to get that right.
I appreciate what you are saying. However, given that in the new health service we have clinical governance, clinical audit and so on, response targets need to be tied to clinical outcome. We need to track what happens through the service from the moment that the call is made. Nobody today has said that we need to look at that big picture, which would indicate whether the targets that are set are correct or incorrect.
Earlier I made a point about the lack of record linkage between the ambulance service, A and E departments and in-patient services. To achieve what you are suggesting, record linkage would be needed all the way through. That is a huge jump, as there are paper-based record-keeping systems in the ambulance service and a variety of not terribly good systems in A and E departments—that is certainly the case in Glasgow, but I cannot speak about Dundee. There are different in-patient systems in different hospitals.
I will ask Mr Spry this question, as it is about Glasgow. I refer him to paragraph 3(b) on page 11, which states:
We have not considered that in detail since the report was published a couple of months ago. We have had conversations with A and E consultants along the lines of our discussions this afternoon. We recognise from those conversations that without adequate record linkage and the ability to audit, we can get so far on the issue but cannot make a decisive impact.
The way in which hospital staff receive ambulance crews when they arrive at hospitals is not raised in detail in the National Audit Office report. During a fact-finding visit, members of an ambulance crew indicated that, in one instance, they spent 90 minutes in a hospital chasing round the corridors looking for staff to receive patients. What action has been taken to deal with that? Are you satisfied with the fact that ambulance crews sometimes spend 90 minutes in hospitals?
One could never be satisfied about that. In London, I spent time on a shift with an ambulance crew; the range of problems that crop up when the crew arrives in hospital is remarkable. The problems can range from searching for somebody to accept the patient—although that is rare, in my experience—to the more common experience of the crew needing to retrieve equipment that is attached to the patient, which can take time.
Can I make a plea for shorter answers? I notice that Mr Brett wants, courageously, to put a toe into the Glasgow water.
I hesitate to do that, but ambulance crews taking patients all the way through to the admitting wards came up at Ninewells hospital. Dr Morrison might be able to say something about that, giving an example of how we try to tackle the issue in Dundee.
This is a hobby-horse of mine. I think that the ambulance service taking all patients to the accident and emergency department and leaving them there is archaic, unkind and unfair. If a GP has seen a patient and decides that they need to be admitted, they should be taken to a bed and not left on a trolley in a corridor.
You have clarified the position that ambulance crews find themselves in, but can you clarify what action has been taken? We have learned that the amount of time ambulance crews are spending in hospitals—90 minutes—is unacceptable, and could result in fatalities. What action is being taken, has been taken and will be taken as a result of this issue repeatedly being raised?
I cannot tell you what action is taken in individual hospitals; it is a matter between the ambulance management and the management of the trust. It is an operational matter that has to be addressed by the appropriate managers in the trust and the ambulance service.
Can we now consider clinical direction and deployment?
We heard some views on that earlier. I think it was Mr Leslie who referred to the health improvement programme and the involvement of the Scottish Ambulance Service with Highland Health Board. It would be interesting to have some elaboration of that and to know how your views on the most important needs of ambulance patients have been taken into account in the preparation of health programmes by the Scottish Ambulance Service. How can the service have the most beneficial impact on the needs of ambulance patients? What involvement has there been by the service helping you to prepare your health improvement plans?
The honest answer to that is, until recently, not much. There are new divisional management arrangements in the ambulance service and we can now see that there is a prospect of fruitful, mutually supportive and helpful conversations between us and the service, to ensure that it contributes to our health improvement planning effectively, just as we are able to influence its. There was relatively little contact at that level, but a lot of contact at what I would describe as the old internal market contract negotiation stuff. That missed the big picture.
When I knew who the new divisional director was for Tayside Health Board, Fife Health Board and Forth Valley Health Board, I made it my business to make early contact, so that the divisional director had access to me, so that I was aware of what the issues were for him, and so that he, likewise, was aware of our plans in Tayside as we consider our services.
Paragraph 4.11 on page 64 of the National Audit Office report says that the service has no specific targets for health gains, although such targets might be useful. In view of that, what scope is there for the service to have a target relating to the Scottish Executive's target for the NHS as a whole, to reduce the number of people dying from coronary heart disease by 2010? What are your views on the use of streptokinase by paramedics? When we were out and about, we heard a plea for that to be added to the list of drugs that they might be allowed to administer with appropriate training and supervision.
That is one way ahead. Early treatment is of proven benefit and, if it can be given early, streptokinase will have benefits. Who gives it is important—it should be the earliest medical person in attendance. The study in the Grampian area has shown that general practitioners giving thrombolysis has enormous benefits. There is no great advantage in the ambulance service giving streptokinase in urban areas, as it can get patients to hospital quickly. In isolated rural areas, however, that may be one of the ways ahead, but I am not sure how to square that with the general practitioners.
Will you elaborate on two points? First, will moves to allow paramedics to use streptokinase be held back because of professional jealousies? I know that they exist, but they must be addressed. Secondly, are there other health gain targets, apart from coronary heart disease, to which the service might be able to contribute?
On professional jealousies, I have no problem whatever with paramedics administering streptokinase, but I do not know how that squares with the general practitioners. At the moment, paramedics are not trained in reading electrocardiograms, but if we had a link to the accident and emergency department with senior staff on hand 24 hours a day to help with interpretation, I would be happy for paramedics to go ahead with that.
I believe that I am right in saying that most ambulances now carry defibrillation equipment to administer electric shocks. That is the sort of thing that we should be able to audit. Information is being gathered, but I do not know whether anyone has had time to assess the impact that that has had. If we could do that, we could assess whether it has made a significant difference to saving lives. It is expensive to conduct that sort of study. All the time, we are balancing that with other needs.
There is a drug—its name escapes me—that can be administered to someone who has taken an overdose—
Naloxone.
That is right.
You asked the right person. [Laughter.]
You obviously have experience of that drug, for some reason.
I knew that my toxicology would come in handy some day.
I know that the ambulance service is pursuing that issue. The greater Glasgow drug action team is keen for the ambulance service to be able to use that drug, as it would help us to achieve earlier interventions that may avert some drug-related deaths.
I believe that that happens in Tayside.
Paragraphs 4.14 and 4.15 on page 65, and figure 27 on page 66, cover skill levels in ambulance crews. It appears that paramedics are not always directed to the emergency services. What impact does that have on health care? Is there any way the service could improve the deployment of paramedics, which, as can be seen from the figure at the bottom of the page, varies widely across Scotland?
The answer would be to have a paramedic in every front-line ambulance, so that any ambulance attending an emergency would have a paramedic. It is difficult to use resources appropriately. You may well take a crew with a paramedic to deal with a certain case just because it is the closest crew, only for something for which a paramedic's skills were more needed to happen elsewhere. Perhaps making more appropriate use of available crews could tie in with the setting of dispatch priorities.
Rural issues rear their heads again. We have paramedics and ambulances that respond to all categories of call, because we need the cover throughout the Highlands. As Dr Baijal has already mentioned, we are concerned about how we can keep up the skills of paramedics and how we use those skills. It would be a bit of a lottery for us to remove paramedics from some of our ambulance stations or response units, because they would not know from one day to the next whether they were going to get a 999 call that required those skills.
I was interested in the earlier exchanges about keeping skills levels up. What evidence is there that skills are lying dormant and that that is having an impact on patients? Has there been research into that, or is the evidence purely anecdotal? On one of our information-gathering visits, some paramedics said that they are not keeping up their skills because they do not see certain types of incident for several weeks at a time.
I know of research involving junior hospital doctors. It is now compulsory for all newly qualified doctors, when they begin their house jobs, to undergo a half-day training session in cardiopulmonary resuscitation. At the end of that session, they are extremely good at CPR, cardiac massage and managing an airway. Three months later, those skills have atrophied considerably. That is well known and has been documented. I do not think that it would be any different for paramedics.
How can we address that problem? Is there any way hospitals can provide some training, refresher courses or assistance? Could paramedics go to an urban centre on exchange visits? Are any health service staff doing that sort of thing at the moment, to keep their skill levels up?
You are talking my language—that ties in with what I was saying about having better links between ambulance service staff and the staff of A and E departments. I would like there to be a much closer relationship, with paramedics spending time in A and E departments, where the requirement for CPR skills is greater. Whether there could be an exchange, with nurses also working in the ambulances, I do not know. I have spoken to our local divisional officer about this, and although our discussions are at the embryonic stage, I think that we could have paramedics spending time in A and E departments. We could also run a rolling course for them.
Is that being replicated elsewhere?
The question about skills retention covers a wider range of medical and clinical services in a rural setting. It does not apply only to the ambulance paramedics. We have secondments out of the rural setting into the urban setting of Inverness. It might be interesting to raise the issue of those who work in urban areas coming to the Highlands and spending a few months up in Bettyhill.
Is the system of secondments formalised?
It is formalised for certain categories of clinicians. General surgeons are seconded regularly, but I do not think that paramedics are often seconded.
In Tayside, we second midwives from smaller units to bigger units.
I am sorry to return to an issue that Mr Brett touched on more than an hour ago, but the nature of the wide-ranging discussion that we have had today has ensured that I must.
Now that there are new local health care co-operatives throughout Scotland, we have an opportunity to talk to groups of GPs and agree practice and ways in which certain issues can be handled. On the way down to Edinburgh, Dr Morrison told me that he is willing to discuss issues with GPs. In the past, it was more difficult to do that as GPs worked exclusively in their own practices and it was difficult to meet them, particularly if they worked in a rural area. I am stealing Dr Morrison's thunder, but I know that he regularly speaks to GPs to give them feedback on issues that have been raised by patients.
I asked what benefits would be achieved for patients. It is interesting to see that, since the evolution of the new partnerships, patients are seeing benefits.
We might not be using the new mechanisms properly yet. The groups have been running only since April and they have had a lot to worry about. However, the forums are available and I encourage people to take issues to them.
GP basic schemes vary throughout the country. There happens to be a pocket of excellence in Perth and Kinross, where a number of interested GPs operate basic schemes that function well with the ambulance service. They are willing to go out to accident scenes to assist ambulance crews. Unfortunately, the situation is not uniform throughout Scotland. I am told that, since the advent of out-of-hours services, there is less enthusiasm for GP basic schemes.
I want to reassure you that there are also pockets of co-operation in the Highlands, even though GPs, ambulance crews and district nurses often operate in remote circumstances.
This has been a long session and we have covered a detailed and important range of issues.
Meeting continued in private until 17:01.