Comparative Analysis of Ambulance Service in the UK and Sacramento City Fire
“finding a sustainable solution by shifting from supply side economics to demand side economics”
Executive Summary
In 1994, the Sacramento City Fire Department assumed the ambulance service for the city of Sacramento and began transporting patients to local emergency rooms. The program began with great success, including decrease response times for ambulances, increased level of patient care, and a new source of revenue for the fire department via billing for transports. However, over the last 20 years the demand for ambulances has increased while the revenue per call has decreased. The demand has increased partly due to a shift in some of the citizen’s expectations for 911 ambulances to provide transportation to the hospital for any desired reason, including to get a prescription refilled. The situation has gotten so bad, that frequently some people dial 911 for an ambulance because they have an appointment but wish to avoid the cost of gas and parking.
Sacramento City Fire Department’s (SFD) historical response to the increasing demand for ambulances is to increase the supply of ambulances. SFD has gone from three ambulances in 1994 to fifteen in 2016. However, the increasing cost of adding ambulances may soon exceed Sacramento’s ability to sustain the process. And when the supply of ambulances is unable to meet the demand, the resulting workload harms the personnel, hospitals, and critical patients.
When ambulances are committed to a nonlife-threatening call, they are not available for an actual emergency. Each transport takes an ambulance out of service for an average of 2 hours, and ambulances used for non-critical patients are potentially putting other citizens at risk. The risk to life is simply too great to continue such practices. The risk to life, the increasing costs, and decreasing revenue suggests that SFD should focus on reducing the demand for 911 ambulances instead of increasing supply.
I have looked at The United Kingdom’s (UK) ambulance service and conducted a comparative analysis with our policies in Sacramento. And based on the UK’s use of priority dispatching, performance measures, and high demand, their challenges and solutions are extremely relevant to SFD’s future.
The UK shifted performance measures from “response time” to “patient outcome” and implemented a solution of “Hear and Treat,” “See and Treat,” and “Treat and Transport” policy. The shift in policy allowed the UK to dedicate the scarce resources of 911 ambulance to critical patients, increasing the effectiveness and efficiency of emergency care.
Measuring patient outcome opposed to response time looks something like this; If a patient is transported by an ambulance with toe pain, arrives at the hospital with toe pain, and is released from the hospital with toe pain, then there is a neutral patient outcome. Opposed to the following scenario; a patient is transported via ambulance for severe shortness of breath, arrives at the hospital with mild shortness of breath, and is released with no shortness of breath, then is a positive patient outcome.
The UK’s evolution is essentially a shift from supply-side economics to demand side economics. It other words, instead of only focusing on increasing the supply of ambulances, the UK implemented ways to decrease frivolous demand for ambulances while focusing on the needs of critical patients.
I understand that the political environment in the UK and Sacramento is vastly different, with each place facing unique challenges. However, an analysis of the UK shows a very busy system struggling with similar problems as SFD, and ultimately finding a sustainable solution by shifting from supply side economics to demand side economics. SFD could learn from the UK’s actions by exploring the following topics:
· Altering priority dispatching
· Developing performance measures that include cost per incident, patient outcome, and return on investment
· Make data-driven policy decisions based on the above performance measures
· Decrease response volume by using a “Hear and Treat” policy
· Implement a Paramedic/Doctor initiated transport refusal with a “See and Treat” policy
· Use alternate forms of transportation to clinics for appropriate patients.
Any action beyond exploration by SFD should include focused input from the medical director, city attorney, and labor union to discuss outline potential liability, costs, and savings of such a program.
Introduction
In 1994, the Sacramento City Fire Department assumed the ambulance service for the city of Sacramento and began transporting patients to local emergency rooms. The program began with great success, including decrease response times for ambulances, increased level of patient care, and a new source of revenue for the fire department via billing for transports. However, over the last 20 years, the demand for ambulances services and the expectation placed on the services have increased while the revenue has decreased. The demand and expectations for ambulances have shifted from emergency use only to any desired transport to the hospital. The situation has gotten so bad, that frequently people dial 911 for an ambulance because they wish to avoid the cost of gas and parking. As you know, it is not uncommon to for a patient to dial 911 to get a ride to the hospital and get their prescription refilled.
Up until 2011, the UK ran a very similar ambulance service to SFD in size, training, performance measures, and response model. This study examined The United Kingdom’s (UK) ambulance service and conducted a comparative analysis with our policies in Sacramento. UK experienced a very similar problem of ambulance abuse and enacted a successful solution in 2011 entitled “Transforming the NHS ambulance services.”
Sacramento City Fire Department’s (SFD) historical response to the increasing demand for ambulances is to increase the supply of ambulances. SFD has gone from three ambulances in 1994 to fifteen in 2016. However, the cost of adding ambulances has grown over the last 20 years.
Coupled with the increasing demand for low-impact calls, the ability to collect a reasonable fee has decreased. The majority of SFD’s ambulance users have federal or state-funded health coverage; Medical or Medicare. Both have increased the requirements to collect on an ambulance transport fee and decreased the amount they are willing to pay for basic transport.
Finally, the greatest concern is that when the ambulances are committed to a non-life-threatening calls, they are not available for real emergencies. Each transport takes an ambulance out of service for an average of 2 hours. Ambulances used for events of inconvenience are potentially putting other citizens at risk. The risk to life is simply too great to continue such practices. The risk to life, the increasing costs, and decreasing revenue suggests that SFD should focus on reducing the demand for 911 ambulances instead of increasing supply.
The UK’s ambulance service
With 63 million people, the UK is the 22nd largest country in the world by population and is slightly smaller than the state of Oregon in square miles. UK’s GDP per capital is 34,000 dollars, making it the 24th wealthiest nation in the world (14 behind the US) based on the World Bank Data. With 679 people per square mile, UK is the 51 most populated nations in the world (131 spots ahead of the US).
Uk’s ambulance service is a part of the National Health Service (NHS), a publicly funded health care system. Ambulance services are provided by 11 regionally based ambulance services, which cost roughly 1.9 billion pounds in 2009–10. Funded from general taxation, the NHS provides medical services at no charge to legal residents in the UK.
The majority of emergency medical personnel work for the (NHS). Typically, ambulances are staffed by one paramedic and an emergency medical technician (EMT). UK’s Health and Care Professions Council regulates their paramedics and EMTs, and function very similar to the EMS providers in SFD.
In 2009–10, the emergency calls (999 for the UK, 911 for SFD) received by the ambulance service were 6.4 million total calls, with 4.7 million transports. Uk’s call volume has increased on average 4 percent per year since 2007–08.
Along with other public agencies in the UK, the NHS’s spending is scrutinized by the National Audit Office (NAO). The NAO is independent of the government and reports to Parliament on the effectiveness and efficiency of public departments, such as the NHS.
In 2011, the NAO conducted an audit of the ambulance service. The result being a fundamental reform of the ambulance service with the goal of increasing patient care of critical patients while saving around 75 million pounds a year, roughly a 4% drop in costs.
Before 2011, the ambulance responses were split into three categories; A- immediately life threatening; B- serious but not life threatening; or C- not immediately serious or life-threatening. These categories determined the response time goals, with category A requiring a response time of fewer than 8 minutes in 75% of the time.
The 2011 audit from the NAO suggested a change in business practices by trying to match the appropriate response model to the need. The result was three tiered system; Hear and treat, see and treat, and see and convey. Essentially, the audit suggested the call taker categorize the call using a decision-making algorithm and then pair the resulting category to one of the new response models. For example, a level C call would be become a “Hear and Treat” call. The call taker would listen to the complaint and provide alternate solutions other than an emergency ambulance.
Also, the UK set new performance measures that focused on clinical quality of care indicators and targets for efficiency saving. The clinical quality of care indicators included outcomes from myocardial infarction, cardiac arrest, and strokes. The efficiency saving included attended per ambulance staff and cost per incident.
Comparative Analysis
Due to UK priority dispatching, performance measures, and increasing call volume from not life threatening calls, it is very comparable to dense cities in the United States, such as Sacramento.
Priority Dispatching
Prior to 2011, UK categorized the urgency of emergency calls into three groups: level A- immediate life threatening, B — serious but not immediate life threatening, and C — not immediately serious or life-threatening. These categories determined the goals for response times but ultimately failed to determine the type of response. To decrease overall response time, the call takers started each call as level A, assuming the worst case scenario prior to truly vetting the call. And even if the call taker did re-categorize the call after more questions, the ambulance response had already started. In other words, UK would still send the most expensive response model to a level C call, they just wouldn’t expect them to get there as fast. As a result, the community was paying a high price for nonemergency calls.
Even though SFD’s categories are opposite, Level D is life threatening, and level A is not immediate, SFD uses the same model respond. Like the UK prior to 2011, each call is started as life threatening prior to questioning, and each response takes an ambulance out of service and is the most expensive response model. In contrast post the 2011 audit, UK stopped priority dispatching and started vetting the calls prior to sending and ambulance to better match the response to the need. As a result, the UK estimates between 100 million pounds to 280 million pounds annual saving and a better patient outcome.
SFD’s driving force for continuing priority dispatching is same as the UK; Performance measures. The reason UK and SFD started each call as life threatening is to get the highest score possible in it performance measure; Response time.
Performance measures
Prior to 2011, the UK main performance measure was response time measured from the time the phone starts ring to the time an ambulance arrives on the scene. Response time drives the dispatchers to get the ambulance moving as fast as possible by categorizing every call as life threatening. Realizing this flaw, the UK switched performance measure to patient outcome, cost for service, and a response time that did not include the phone call.
SFD suffers from the same flaw, as its primary performance measure of effectiveness is response time that includes the phone call. And SFD lacks any patient care or cost efficiency performance measure, leading SFD to use the most expensive response model each time while not tracking life threatening calls missed because all the ambulances are dispatched.
Demand
Similar to SFD, the UK’s ambulance system has seen a steady increase in call volume. In 2007–08, UK’s call volume for ambulance services jumped 9 percent, causing the cost of service to jump 19 percent. As a result, the cost per call increased 10 percent. As you know SFD has also seen a steady increase in call volume and costs, however, since the 2011 audit, UK has implemented multiple programs for reducing demand.
The UK manages demand through at three points through the cycle of the call; hear and treat, see and treat, and see and transport.
Hear and treat allows the dispatcher to resolve the call over the phone by referrals to clinicians in the area without the need for an ambulance. Hear and treat deduces the number of dispatches, deals with the problem promptly, ambulance capacity is reserved for better use, ambulance staff is less impacted, and the patient is seen closer to home. Finally, for safety hear and treat interventions err on the side caution, sending a response model if there is any doubt about the severity.
SFD has no practical solution compatible to hear and treat. As a result, SFD’s call volume continues to increase, simple solutions for patients are delayed, ambulances are less available, ambulance staff is overworked, and patients are frequently transported across town.
See and treat allows the ambulance crew to resolve the incident on-scene without the need for transport to an emergency room. See and treat reduces the total call time the ambulance is committed, uses the crews training effectively, reduces the impact on the emergency room, decreases treatment time, and keeps the patient closer to home.
And although SFD can technically “see and treat” a patient on the scene if the patient refuses to be transported, there are significant barriers to doing so. First, the patient must insist on the “see and treat” policy and sign a legal form stating they are refusing medical advice and insist on staying home. And second, SFD’s informal policy of “you call, we haul” institutionalizes the mindset that every patient is to be transported to the hospital regardless of the complaint. SFD’s formal and informal policies decrease ambulance availability for life-threatening calls, increases the impact in the emergency room, increases treatment time, and potentially moves the patient across the city.
UK’s “see and transport” is essentially the same as SFD’s, except that the “hear and treat” policy and the “see and treat” policy the UK deploys ensures more ambulances available for life-threatening calls with better-rested crews.
Also, the UK has implemented an ‘111’ number which provides an alternate for those callers who do not have life-threatening conditions. The ‘111’ number helps ensure patients with an urgent need get help while guaranteeing that ambulance resources are available for medical emergencies.
SFD implemented a similar system in 2010 call ‘311’. However, ‘311’ only deals with city services such and water and streets and has no capacity for medical needs. Lacking an ‘111’ type system forces all medical requests to go through the 911 system and ultimately have an ambulance dispatched on the smallest of medical problems.
Finally, the UK has formed partnerships to reduce calls from particular patient groups. For example, falls account for 10 percent of the UK’s ambulance calls. Fall teams have been established in some areas by the ambulance service in conjunction with social services to provide advice and prevention service to people at risk of repeated calls.
SFD has no real partners to assist with repeat 911 users, such as the homeless in the area. Many of the homeless need medical services, but not a code three ambulance and an emergency room. A partnership with social services, such as the UK to refer at-risk patients could significantly reduce demand.
Considerations
Liability
The liability of delaying response due to a “Hear and Treat” policy or a “See and Treat” policy should be quantified and vetted. UK’s health care system is different that the United States based on the fact that is a national health care system funded by public taxes. The liability of a situation where a patient suffers additional injury or death due to a policy that delayed treatment or transport would be spread out across the nation, opposed to Sacramento where a lawsuit could leave the City of Sacramento open to a large liability. The probability of a lawsuit should be estimated based on call volume and patient contact rates to compare the potential loss against the potential saving of such policies.
Public image
Altering the public image of the fire service should also be a concern. Currently, if a citizen calls 911, the fire department responds regardless of the need. This level of consistency builds confidence and trust between the community and the fire department. A new policy of “Hear and Treat”, where the fire department does not send a responding unit to a minor medical aid may have a negative effect on community support and funding.
Political environment — Labor/admin
The Labor Union may feel threatened by a decrease in call volume from a “Hear and Treat” or a “See and Treat” policy. The Labor Union’s potential reaction may seem counter-intuitive because it would decrease the workload for their members, but it may also decrease demand for employees, essentially decreasing jobs. Any policy change in the respond model should be presented and ultimately endorsed by Labor.
Contingencies
If any of the new policies prove to more costly in liability, good will, or political currency, they can easily be rescinded and replaced with the current form of business. Also, the new policies can be separated and individually implemented. For instance, if the “Hear and Treat” policy cost too much community goodwill, it can be removed and replaced with “See and Treat” for that category of the call also.
Conclusion
Currently, SFD functions very similarly to the UK before 2011; through the use of priority dispatching and the reliance of response time as a performance measure. However, in 2011 the UK evolved and implemented new procedures to reduce demand, reduce costs, and increase the quality of patient care. SFD should look closely at the UK’s ambulance transformation and consider if the policies can fit our environment.
