- Email: [email protected]
Ambulance demand
AMBULANCE DEMAND A New 1.ook at the Relation of Ambulance and Hospital Records V.
WIIITA
K ER,
O.t~.L:., l:.l.a.O.
('lli(J..tnd, ulam'e Officer, }'orks/tire fVest Riding ()~ta,ty Council Tii~- Amhulancc Service under the N:.itional Heahh Service Act is now reasona n y established x~ilh several years c,f experience and statistics to draw upon. Scrx ice> ma5 be cxzlmincd and moditication, improvements and even complete changes re:H, bc considered. There are still, however, no recognised local or n:,ti~mal means of measuring ambulance user demand, or of assessing whether it i~ rcasunablc. Hospitals return the number of actual attendances by outpaticnt~, for each .\car endin,,~ .gist December. Ambular~ce Authorities return the number {~t"patients attending or discharged by' ambulance (an out-patient hcrc bcingcountcd astwo), for c a c h y e a r e n d i n g 3 1 s t March. [t is impossible {() compare the txvo records as each covers a difl'erent 12-month period and L;bCS it different meth~:~d of calculation. "Io tind a x~av to relate ambulance and hospital services statistics as a m~..an~, of mca,,,uring and tOtalraring the demand made upon Ambulance Scr,,it.cs tw particular hospitatls, an experiment has been conducted between a regional hospital t~oard and certain hospital and ambulance service officials. l h e experiment began at one hospital served by one ambulance authority. qhc ',tmbulancc service recorded specially the number of actual attendances of out-patic/-lls u.~ing arllbtlkttlcc transport. The record revealed at the 3,'ear end lhat ¢~i"l.hc total (~ut-paticnt attcndances, c)ne in every 8.7 used an ambulance. l h e cxpcrimcn~ was extended to cover other hospitals, until in I957 a large scale ~,urvcv x~as conducted. Fourteen ambulance authorities and 54 selected hoN~ital~, served exclusively by these authorities were included. The list covered .-,omc of the [argc,,,t ho~;,l)itals,in the country. A single style of record was adopted and maintained by each ambulance authority. By the use of this record, the information collected could be collated and compared with each hospital's ~,tandard record. The value of this experiment lies in this factual evidence beh-lg available to support variatidns in comparable figures. Among the 54 hospitals surveyed were 30 general.hospitals with an average out-patient ambulance attendance of 1 in 9-49 and 8 mainly general hospitals x~i~h an axeragc of 1 in 6.0t. The ratio of patient attendances by ambulance it~ respect of all hospitals ,,'aries between 1 in 2"5 and I in 19"5. Why, should there bc such a difference in ratios between hospitals'? Why should general hospital.,, have a better average than mairdy general hospitals? The experiment :,ugge,qs that out-patient attendances by ambulances should be between 1 in 10 and I in 8. l tospita!s with a wholly rural and/or country-town catchment area have a suggested ratio of about 1 in 5. Specialist hospitals, due to their lar,,c catchment areas brought about by specialisation, may have a low average, as also is the case of hospitals with large geriatric out-patient departments. 154
AMBULANCE
DEMAND
155
The next stage was to use the information collected concerning a great number of hospitals. Experience had shown that discussion at individual and hospital group level was by far the best. It cannot be said what ratio ambulance user at a particular hospital should be. There must be joint discussions, examination of tile fitcts and the making of assessments. It is essential that each hospilal be viewed as a separate consideration before comparison with a similar hospital can be attempted. No two hospitals are alike in either treatment facilities, location or catchment area. Increased movement of inpatients between hospitals for specialist out-patient treatment indicates how hospitalisation principles and treatment methods are changing. Is it more economical to increase medical equipment or is it better to transport patients between hospitals? If additional medical equipment and staff cannot be fully employed, it is nationally cheaper to transport the patient--within limits. Another development to be taken into account is the introduction of"day hospitals". At the hospital where the experiment began, ambulance use was 1 in 8"9. This figure improved to 1 in 9"7, chiefly as the result of the hospital staff's interest in the experiment leading to more positive control of authorisations. The mere presentation of comparative figures to a hospital can be very effective. Hospitals low on the list are naturally concerned to seek out the reason. Hospital authorities do not realise how much they call upon the ambulance service and are most surprised with the extent of their demands. One hospital executive preferred to keep his own record of ambulance transport authorisations~his figure turned out to be much less than that of the ambulance service. The difference was explained by unofficial authorisations from the hospital being accepted in good faith by the ambulance service. Again, at one particular hospital, ambulance use had increased although the total out-patient attendances had decreased and in one hospital department, staff had increased from two to five during the experiment. The question was--why, with more hospital staff and fewer patients, had there been more ambulance users'? The final answer showed that there was lack of authorisations, revealing that new staff had not been briefed in tile proper use of the service. Comparative statistics being information to light and emphasise their importance as a talking point. They provide facts for ambulance and hospital executives to discuss at local level and local liaison is much more fruitful than Ministry circulars. It is part of a local authority's job at local level to ensure that its ambulance service is being properly used. There are, as yet, no standard measurement of demand and no statistical evidence to provide means of control, however limited. The experiment indicates the possibilities of producing some kind of yardstick although it would mean changing the pattern of existing records. For the first time in the history of the N.H.S. there has become available a factual record to discuss with hospitals. The record is a practical proposition,
156
PUBLIC
HEALTH
VOL.
LXX1X
NO.
3
particularly for small groups of authorities. On a national scale it would be rather more difficult except in the case of a number &selected hospitals throughout the country--the difficulties would be less on a regional basis. The partieular concern of ambulance authorities is not with all hospitals, however, but with those haveing out-patient departments. The aim of such an investigation or better still, a permanent national record of comparable statistics, would be to provide a better and more efficient service for patients within the limits of the existing service. On the one hand it may be that demand cannot be reduced, in which case the statistical data could at least be used to engender closer working relationships between hospital and ambulance service. It could be used to expose weaknesses and generally to tidy up otherwise dormant considerations. This calls for co-operation with the hospital service in the broadest sense. On the other hand, should, through this or any other means the number of ambulance users be reduced, this should not be taken as an opportunity to reduce the number of vehicles and staff. Every service is overloaded more often than not. There is need for a concerted endeavour-To reduce the mileage and time of the "'group collection" journeys. To reduce the time spent by out-patients waiting at hospitals for the return journey to their home. To provide an individual and personal service to all stretcher patients. To help the hospital service to maintain its treatment programmes by keeping closer to appointment times. To eradicate unnecessary journeys and inefficient use of ambulances. All this has one object in view~to increase vehicle availab,ility, without which all other factors contributing to patient welfare lose considerable value.
WIIITA
K ER,
O.t~.L:., l:.l.a.O.
('lli(J..tnd, ulam'e Officer, }'orks/tire fVest Riding ()~ta,ty Council Tii~- Amhulancc Service under the N:.itional Heahh Service Act is now reasona n y established x~ilh several years c,f experience and statistics to draw upon. Scrx ice> ma5 be cxzlmincd and moditication, improvements and even complete changes re:H, bc considered. There are still, however, no recognised local or n:,ti~mal means of measuring ambulance user demand, or of assessing whether it i~ rcasunablc. Hospitals return the number of actual attendances by outpaticnt~, for each .\car endin,,~ .gist December. Ambular~ce Authorities return the number {~t"patients attending or discharged by' ambulance (an out-patient hcrc bcingcountcd astwo), for c a c h y e a r e n d i n g 3 1 s t March. [t is impossible {() compare the txvo records as each covers a difl'erent 12-month period and L;bCS it different meth~:~d of calculation. "Io tind a x~av to relate ambulance and hospital services statistics as a m~..an~, of mca,,,uring and tOtalraring the demand made upon Ambulance Scr,,it.cs tw particular hospitatls, an experiment has been conducted between a regional hospital t~oard and certain hospital and ambulance service officials. l h e experiment began at one hospital served by one ambulance authority. qhc ',tmbulancc service recorded specially the number of actual attendances of out-patic/-lls u.~ing arllbtlkttlcc transport. The record revealed at the 3,'ear end lhat ¢~i"l.hc total (~ut-paticnt attcndances, c)ne in every 8.7 used an ambulance. l h e cxpcrimcn~ was extended to cover other hospitals, until in I957 a large scale ~,urvcv x~as conducted. Fourteen ambulance authorities and 54 selected hoN~ital~, served exclusively by these authorities were included. The list covered .-,omc of the [argc,,,t ho~;,l)itals,in the country. A single style of record was adopted and maintained by each ambulance authority. By the use of this record, the information collected could be collated and compared with each hospital's ~,tandard record. The value of this experiment lies in this factual evidence beh-lg available to support variatidns in comparable figures. Among the 54 hospitals surveyed were 30 general.hospitals with an average out-patient ambulance attendance of 1 in 9-49 and 8 mainly general hospitals x~i~h an axeragc of 1 in 6.0t. The ratio of patient attendances by ambulance it~ respect of all hospitals ,,'aries between 1 in 2"5 and I in 19"5. Why, should there bc such a difference in ratios between hospitals'? Why should general hospital.,, have a better average than mairdy general hospitals? The experiment :,ugge,qs that out-patient attendances by ambulances should be between 1 in 10 and I in 8. l tospita!s with a wholly rural and/or country-town catchment area have a suggested ratio of about 1 in 5. Specialist hospitals, due to their lar,,c catchment areas brought about by specialisation, may have a low average, as also is the case of hospitals with large geriatric out-patient departments. 154
AMBULANCE
DEMAND
155
The next stage was to use the information collected concerning a great number of hospitals. Experience had shown that discussion at individual and hospital group level was by far the best. It cannot be said what ratio ambulance user at a particular hospital should be. There must be joint discussions, examination of tile fitcts and the making of assessments. It is essential that each hospilal be viewed as a separate consideration before comparison with a similar hospital can be attempted. No two hospitals are alike in either treatment facilities, location or catchment area. Increased movement of inpatients between hospitals for specialist out-patient treatment indicates how hospitalisation principles and treatment methods are changing. Is it more economical to increase medical equipment or is it better to transport patients between hospitals? If additional medical equipment and staff cannot be fully employed, it is nationally cheaper to transport the patient--within limits. Another development to be taken into account is the introduction of"day hospitals". At the hospital where the experiment began, ambulance use was 1 in 8"9. This figure improved to 1 in 9"7, chiefly as the result of the hospital staff's interest in the experiment leading to more positive control of authorisations. The mere presentation of comparative figures to a hospital can be very effective. Hospitals low on the list are naturally concerned to seek out the reason. Hospital authorities do not realise how much they call upon the ambulance service and are most surprised with the extent of their demands. One hospital executive preferred to keep his own record of ambulance transport authorisations~his figure turned out to be much less than that of the ambulance service. The difference was explained by unofficial authorisations from the hospital being accepted in good faith by the ambulance service. Again, at one particular hospital, ambulance use had increased although the total out-patient attendances had decreased and in one hospital department, staff had increased from two to five during the experiment. The question was--why, with more hospital staff and fewer patients, had there been more ambulance users'? The final answer showed that there was lack of authorisations, revealing that new staff had not been briefed in tile proper use of the service. Comparative statistics being information to light and emphasise their importance as a talking point. They provide facts for ambulance and hospital executives to discuss at local level and local liaison is much more fruitful than Ministry circulars. It is part of a local authority's job at local level to ensure that its ambulance service is being properly used. There are, as yet, no standard measurement of demand and no statistical evidence to provide means of control, however limited. The experiment indicates the possibilities of producing some kind of yardstick although it would mean changing the pattern of existing records. For the first time in the history of the N.H.S. there has become available a factual record to discuss with hospitals. The record is a practical proposition,
156
PUBLIC
HEALTH
VOL.
LXX1X
NO.
3
particularly for small groups of authorities. On a national scale it would be rather more difficult except in the case of a number &selected hospitals throughout the country--the difficulties would be less on a regional basis. The partieular concern of ambulance authorities is not with all hospitals, however, but with those haveing out-patient departments. The aim of such an investigation or better still, a permanent national record of comparable statistics, would be to provide a better and more efficient service for patients within the limits of the existing service. On the one hand it may be that demand cannot be reduced, in which case the statistical data could at least be used to engender closer working relationships between hospital and ambulance service. It could be used to expose weaknesses and generally to tidy up otherwise dormant considerations. This calls for co-operation with the hospital service in the broadest sense. On the other hand, should, through this or any other means the number of ambulance users be reduced, this should not be taken as an opportunity to reduce the number of vehicles and staff. Every service is overloaded more often than not. There is need for a concerted endeavour-To reduce the mileage and time of the "'group collection" journeys. To reduce the time spent by out-patients waiting at hospitals for the return journey to their home. To provide an individual and personal service to all stretcher patients. To help the hospital service to maintain its treatment programmes by keeping closer to appointment times. To eradicate unnecessary journeys and inefficient use of ambulances. All this has one object in view~to increase vehicle availab,ility, without which all other factors contributing to patient welfare lose considerable value.