Courtesy of Mary Wakefield @ The Spectator:
Last month I wrote about the weird exodus of paramedics from London’s ambulance service. Flies would blanch at the rate they’re dropping, and so I was curious — and also anxious. Everyone who lives in this heaving city relies upon 999, and 999 relies upon paramedics.
The official reason, given to me by Mr Jason Killens, the tough-sounding director of operations at the London Ambulance Service (LAS), was that they’re leaving because they’re underpaid. But as I wrote back then, I wasn’t convinced.
It turns out Mr Killens wasn’t quite convinced either, because since we spoke, the LAS have begun an internal inquiry into the matter — and as it happens, inadvertently, so have I. Over the past few weeks I’ve been swamped by emails and letters from desperately unhappy paramedics. I’ve spoken to many of them; and can now present the results of my own inquiry. It might also (sad to say) be of interest to the other NHS ambulance trusts around the country — all nine of them from north to south, because it seems increasingly clear that London’s problems are echoed nationwide.
First you need to understand that London’s 999 service is on the very edge of melting down. The number of calls has risen dramatically and ambulances are sent willy-nilly to all manner of pointless non-emergencies. There are supposed to be systems in place that sort the hypochondriacs from the heart attacks, but for one reason or another they are all inadequate. The operators at 111, for instance, are untrained and risk-averse, so they send ambulances to the slightest sniffle. For a 999 operator, the words ‘chest pain’ or ‘difficulty breathing’ automatically mean an ambulance, though it’s often just a panic attack on the line. The service is so stretched that ambulance crews no longer return to their stations to recover between emergencies, but must circle the city all shift long and often do overtime.
So it’s hard, gruelling work, but this in itself isn’t why paramedics are dropping out, nor is it the fault of the ambulance service. It’s just the familiar bloody crunch of a free service, one to which people feel entitled, colliding with limited funds.
What is the fault of LAS management, though, is how they have chosen to respond. They have a duty of care to their exhausted paramedics; they should be thinking hard about how to improve the system. Instead, in a panicked bid to save face and hit targets, they have taken to cracking the whip over their frontline staff — driving them on until they snap or break down.
Last week I had an email from another whistleblower: ‘Surge Purple called again. Help!’ ‘Surge Purple’ is a perfect example. The ‘Surge Plan’ is what our ambulances follow when there’s an emergency. Surge Amber means a mini-crisis; Surge Red is bad news; Purple means a major incident or a catastrophic situation. A Surge Purple was declared during the 7/7 London bombings, for instance: it’s a serious call.
Surge Purple means the whole front line of the London Ambulance team — 999 call dispatchers, drivers and paramedics — racing flat out, working overtime, getting by on adrenaline in place of sleep. It means staff on holiday or sick are badgered to come in. It should by definition be an almost unheard-of measure, but Surge Purples are being called regularly these days: two in June this year, more in July — and why? Simply because there are far, far too many calls to deal with. Managers fear they won’t hit the government-set targets, so they press the panic button and up the pressure on already run-ragged ambulance crews.
It’s not just cruel; it’s dangerous too. During one Surge Purple, the LAS apparently decided that all ambulances should respond to all calls — even non-emergencies — on ‘blue’, meaning lights on, racing top speed. Under normal circumstances an ambulance will only drive on blue if the patient is critically ill, because it’s risky and stressful, but despite complaints from the crews, the LAS was said to be adamant. So London sounded with sirens. Blind-tired drivers served frantically around town, dodging pedestrians. Why? Not to save lives (it perhaps even endangered them), but just to catch up, to pretend it was all OK for one more desperate day.
Even in these circumstances, if their immediate bosses, the duty officers and area managers of the ambulance stations, supported them, London’s paramedics might not be opting out. But if the emails and letters I’ve received are to be believed, a culture of bullying, fear and paranoia has crept in. Frontline staff are working beyond the point of normal endurance — skeleton crews on week-long Surge Purples — but if they become ill, from lifting heavy patients or from stress, management gets difficult. If you begin to sift through local news stories, you can see this panicked bullying has become the reflex response of management in ambulance services around the country — a product perhaps of the wrong people, over-promoted and at sea in the chaotic system. Just as a bad workman blames his tools, so an incompetent manager blames his staff, and for want of any other answer, simply pushes them ever harder.
Last December the Worcester News reported that a whistle-blowing paramedic with the West Midlands service had claimed staff felt ‘downtrodden and bullied’. In April this year Dr Anthony Marsh, head of the East of England ambulances, edged his head above the parapet to warn that staff were ‘tired, overworked and frustrated’. Just a few weeks ago, a source from South Central Ambulance Service told an Oxfordshire radio station that there had been a huge exodus of staff, because they felt undervalued by their bosses. ‘It’s us versus them between the front-line crews and management.’
Paramedics suffer badly from post-traumatic stress disorder, far more than the police or the fire brigade, but they work harder, retire later, and there is no room these days for mistakes. If, in the general run of handing patients over to A&E, a single box is left unticked, disciplinary proceedings begin. ‘Make a mistake on your paperwork, and you may as well kiss your job goodbye’: I’ve heard this many times. I’ve been told of staff being disciplined for simply questioning management’s decisions, and of nervous breakdowns. A former paramedic with the East Midlands service told the Nottingham Post, ‘Someone will go to a child death, which is awful, and from there they can immediately go to another. Anyone would go to pieces after that job. But that’s made irrelevant if targets need to be hit.’ I had coffee with a former member of the LAS who claimed there was an unofficial paramedic suicide-risk list held by HQ. As he spoke, his eyes flickered anxiously from right to left, as if management might be listening. Paranoid, yes, but far from unusual. To a man, I’ve found they’re terrified of management.
And this is why Jason Killens has so many ‘unknowns’ on his paramedic ‘reasons for leaving’ chart. They don’t dare tell the truth. Management has the power to strike paramedics from the register. They might want to work elsewhere in the health service and they worry about reprisals.
Now, I expect at this point Mr Killens has already planned a cross letter to The Spectator. But these aren’t allegations — this is simply what staff say to someone who they think might care.
The London Ambulance Service top brass claim to be concerned about the crisis in their service, as well they should be. They say they are taking steps to improve the working lives of their ambulance crews and recruit new frontline staff. But my light reading these past few weeks has been the minutes from their monthly board meetings and they’re as puzzling as the emails from the paramedics are disturbing.
Take July. Each board member present had a report in front of them which laid out, in graphs and bullet points, roughly the picture I’ve painted above: ambulances run almost constantly on emergency ‘code red’; use of Surge Purples (which I assume are technically supposed to trigger some sort of inquiry); the haemorrhaging of staff. There has also been a ‘steep rise in the number of complaints received by the Patient Experiences Department’. So why, then, does no one seem to care? Last month’s minutes start with a little talk from a deaf member of the LAS, and the first concern of the service’s chief executive, Ann Radmore, is that not enough is being done to make it easier for people who are hard of hearing to join the service.
She then addresses the ‘staff turnover’ issue, but it’s almost as if she’s never spoken to a paramedic: she suggests that they’re all leaving just because there is such a demand for their skills elsewhere. The board seem united in thinking that the answer is not to improve a London paramedic’s lot, but to ship more in from abroad. A chap called Nick wonders about recruiting from China; someone else mentions that a recruitment drive is to begin in Australia. A chap called Theo de Pencier, who I hope was joking in a black sort of way, suggests that next year’s Rugby World Cup might ‘also attract people to work in London’. De Pencier also worries about the impact of poor air quality in London on staff health. Then they all disperse until next time.
It’s nice that Theo’s concerned about the air quality — next perhaps he’ll suggest letting them eat cake — but it’s terrifying to see how little any of the board seem to understand the problems on their own front line.
So the first recommendation of this Spectator inquiry is that if Mr Killens and Ms Radmore want to keep their paramedics — and they urgently need to — they must begin by listening to them. This of course goes for every chief executive of every ambulance trust across the country. I’ve heard more than once that the much-admired former chief exec Peter Bradley spent an hour and a half in each station every year, chatting and trying to understand. Perhaps Ms Radmore might do the same.
After listening to them, they’ll understand that no amount of recruiting from Australia (where I gather Jason Killens is currently scouting about) is going to help. Staff will come, and then will leave, and the trouble will continue.
My second recommendation is that the management comes clean. Paramedics are the canaries in the coal mine of 999. They’re dropping out because the whole system is poisonous. You can’t operate on Surge Purple for ever. Jeremy Hunt, the Secretary of State for Health, and his team were concerned about the comments from paramedics under my previous article. Mr Hunt was worried enough to promise to look into the issue, so now is the time for all those in charge of these miserable, collapsing ambulance services to stop hoping the problem will just evaporate some day, and take action. They should join together to urge the Health Secretary to reconsider 111; make sure ambulances are reserved for proper emergencies; and, most of all, treat paramedics with the respect they deserve.
This article first appeared in the print edition of The Spectator magazine, dated 30 August 2014