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Ambulances
797
THE LANCET LONDON: SATURDAY, NOY. 29, 1947
Ambulances RELIABLE arrangements for moving patients by ambulance are an important element in any medical service. Little is heard of the preparations for the ambulance system in the National Health Service, but its organisation is being considered. Ambulance services in this. country were largely amalgamated during the war, but they have now been restored to their pre-war owners and show tendency to revert to their pre-war standards. Is this necessarily a good thing ?1 Ought we not to use the opportunity for a fresh approach ?1 In greater London, for example, before the war there were various ambulance services. The greatest was that of the London County Council, operating within the boundaries of the county. Outside those impassable boundaries there were many small ambulance services owned by the boroughs and the counties. Borough ambulances could take the patient from the borough to any hospital but not vice versa, and county ambulances were to be used only for the county hospitals. Rates of payment were highly diverse : some ambulances were free, while some had a mileage rate, and the patient proceeding to a voluntary hospital in a L.C.C. ambulance had to pay cash down or be taken willynilly to a L.C.C. hospital. Finally there were private ambulances-more particularly those of the Joint Committee of St. John and the Red Cross-which disregarded all boundaries and charged a moderate a
fee. In the
a
new
health service the ambulances will
presumably be free ; so one problem at least will disappear. Indeed, the L.C.C. has already dropped its charge for journeys to hospital when the hospital calls the ambulance.
But what of the boundary Presumably borough and county boundaries will disappear, for in a national service they will have no significance. Will they be replaced by regional boundaries ?1 Since it has been said that regional boundaries are to be no bar to the movement of patients, presumably ambulances will be able to cross them. Up to this point the new system must of itself be an improvement, provided the larger ambulance- services do not acquire a larger bureau-
question ?
But there remains a risk cracy to hinder them. that the present speed of dealing with cases will be accepted as a standard to maintain rather than as a basis for improvement. Despite the somewhat rosy statistics which are published, we have heard doctors complain of interminable delays in obtaining ambulances. Further information would be welcome, but it seems at least to be clear that an hour’s delay before the’ ambulance starts is not unusual at any time of year-particularly at the " peak " hours
of midday and evening-and that in winter the delay is often much greater. Admittedly," if the case is be one of accident or can certified as life or death " an accident ambulance can be called, and this will start more orless at once. But the bulk of patients needing immediate admission to hospital are not in this desperate plight ; so, though they may be very ill and the anxiety of their friends and doctor very great, they have to wait-to their medical disadvantage where (in pneumonia for example) active treatment should begin at once. Presumably this is because there are not enough ambulances to go round, and because old ones cannot be replaced. Is it, however, certain that a sufficient expansion is envisaged not only to ensure that patients shall not be kept waiting unduly, but also to meet the added requirements that the National Health Service
will bring ? There are various concealed requirements which rationalisation of hospital work will reveal more clearly. Thus it is evident that something will have to be done about the patientwho needs outpatient treatment but is unable to travel to and from hospital, either because of his physical disability or (in the country) because public transport is lacking. Nowadays such a man either goes without the treatment or is given a hospital bed which could be put to It looks as though the scope of the better use. ambulance service must be enlarged to include the wide use of sitting ambulances, to work in connexion with outpatient departments. Running a large ambulance service is a technical job which few are qualified to undertake ; and it is not for the inexperienced to suggest how these necessary improvements should be made. The county health authorities, however, have great experience, and they are to bear the whole burden in the future. We trust that they are dissatisfied with the present service and are planning boldly for something better. ,
Cholera and Hysteria CHOLERA inspired the first attempt at international regulation of quarantine procedures, and the Egyptian cholera outbreak has revealed the flimsy foundation which a hundred years of such efforts have been based. Since the first quarantine conference in 1851 those concerned with international quarantine have had a twofold purpose : on the one hand, they have sought to promote measures which would prevent the spread of disease from country to country, and on the other hand they have tried to obtain agreement on an upper limit of severity for such measures, which would prevent unnecessary interference with trade and travel. In the Egyptian outbreak the first of these objectives-the prevention of international spread-seems to have been achieved : for cholera has not so far appeared in any other country west of the Persian Gulf, and further epidemic extension is unlikely now that the incidence in Egypt has declined and the Mecca pilgrimage has been concluded. It is the second objective-the avoidance of undue dislocation of trade and travel-which has not been attained, and the story of the failure can be read between the lines of the official Weekly Epidemiological Record of the World Health Organisation and in the press. on
THE LANCET LONDON: SATURDAY, NOY. 29, 1947
Ambulances RELIABLE arrangements for moving patients by ambulance are an important element in any medical service. Little is heard of the preparations for the ambulance system in the National Health Service, but its organisation is being considered. Ambulance services in this. country were largely amalgamated during the war, but they have now been restored to their pre-war owners and show tendency to revert to their pre-war standards. Is this necessarily a good thing ?1 Ought we not to use the opportunity for a fresh approach ?1 In greater London, for example, before the war there were various ambulance services. The greatest was that of the London County Council, operating within the boundaries of the county. Outside those impassable boundaries there were many small ambulance services owned by the boroughs and the counties. Borough ambulances could take the patient from the borough to any hospital but not vice versa, and county ambulances were to be used only for the county hospitals. Rates of payment were highly diverse : some ambulances were free, while some had a mileage rate, and the patient proceeding to a voluntary hospital in a L.C.C. ambulance had to pay cash down or be taken willynilly to a L.C.C. hospital. Finally there were private ambulances-more particularly those of the Joint Committee of St. John and the Red Cross-which disregarded all boundaries and charged a moderate a
fee. In the
a
new
health service the ambulances will
presumably be free ; so one problem at least will disappear. Indeed, the L.C.C. has already dropped its charge for journeys to hospital when the hospital calls the ambulance.
But what of the boundary Presumably borough and county boundaries will disappear, for in a national service they will have no significance. Will they be replaced by regional boundaries ?1 Since it has been said that regional boundaries are to be no bar to the movement of patients, presumably ambulances will be able to cross them. Up to this point the new system must of itself be an improvement, provided the larger ambulance- services do not acquire a larger bureau-
question ?
But there remains a risk cracy to hinder them. that the present speed of dealing with cases will be accepted as a standard to maintain rather than as a basis for improvement. Despite the somewhat rosy statistics which are published, we have heard doctors complain of interminable delays in obtaining ambulances. Further information would be welcome, but it seems at least to be clear that an hour’s delay before the’ ambulance starts is not unusual at any time of year-particularly at the " peak " hours
of midday and evening-and that in winter the delay is often much greater. Admittedly," if the case is be one of accident or can certified as life or death " an accident ambulance can be called, and this will start more orless at once. But the bulk of patients needing immediate admission to hospital are not in this desperate plight ; so, though they may be very ill and the anxiety of their friends and doctor very great, they have to wait-to their medical disadvantage where (in pneumonia for example) active treatment should begin at once. Presumably this is because there are not enough ambulances to go round, and because old ones cannot be replaced. Is it, however, certain that a sufficient expansion is envisaged not only to ensure that patients shall not be kept waiting unduly, but also to meet the added requirements that the National Health Service
will bring ? There are various concealed requirements which rationalisation of hospital work will reveal more clearly. Thus it is evident that something will have to be done about the patientwho needs outpatient treatment but is unable to travel to and from hospital, either because of his physical disability or (in the country) because public transport is lacking. Nowadays such a man either goes without the treatment or is given a hospital bed which could be put to It looks as though the scope of the better use. ambulance service must be enlarged to include the wide use of sitting ambulances, to work in connexion with outpatient departments. Running a large ambulance service is a technical job which few are qualified to undertake ; and it is not for the inexperienced to suggest how these necessary improvements should be made. The county health authorities, however, have great experience, and they are to bear the whole burden in the future. We trust that they are dissatisfied with the present service and are planning boldly for something better. ,
Cholera and Hysteria CHOLERA inspired the first attempt at international regulation of quarantine procedures, and the Egyptian cholera outbreak has revealed the flimsy foundation which a hundred years of such efforts have been based. Since the first quarantine conference in 1851 those concerned with international quarantine have had a twofold purpose : on the one hand, they have sought to promote measures which would prevent the spread of disease from country to country, and on the other hand they have tried to obtain agreement on an upper limit of severity for such measures, which would prevent unnecessary interference with trade and travel. In the Egyptian outbreak the first of these objectives-the prevention of international spread-seems to have been achieved : for cholera has not so far appeared in any other country west of the Persian Gulf, and further epidemic extension is unlikely now that the incidence in Egypt has declined and the Mecca pilgrimage has been concluded. It is the second objective-the avoidance of undue dislocation of trade and travel-which has not been attained, and the story of the failure can be read between the lines of the official Weekly Epidemiological Record of the World Health Organisation and in the press. on