Back in December 2017 I was part of a team working to improve access to the Directory of Services (DoS). The DoS identifies where best to send a patient by combining symptom information with local service availability. It was originally designed for NHS 111, but has great potential for clinicians and healthcare professionals in other areas of urgent and emergency care.
The aim of our project was to understand the needs of users outside of NHS 111. Therefore, we undertook a series of interviews and observations of healthcare professionals at work. We wanted to understand how they worked, in order to understand how best to enable them to access the DoS (if, indeed, we found they needed it).
One group of users we identified was ambulance services and paramedics. Some ambulance services were initially hesitant to work with us during winter, when services are under the most pressure. Although we were careful not to be a burden, we understood their concerns. Thankfully, many services were happy to welcome us in with open arms – and it’s a testament to this openness that the outputs of our discovery ended up delivering real value.
Heading north
So, on a Sunday night in December, I headed north to Middlesbrough and Stockton-on-Tees ambulance station. I was there to observe a full 6.30am - 6.30pm ambulance shift, accompanying a crew as they treated patients during the first episode of heavy snow of winter 2017/18. I had no idea what to expect.
Arriving at 6am on the Monday morning at the ambulance station, it’s safe to say my welcome was much like the weather - frosty. I was equipped with a fluorescent jacket and shown to my seat in the back of the ambulance. I waited while equipment was prepared and drugs checked out. Then it was time to clock on for the shift. Immediately we were off with blue lights and sirens to a category one patient - chest pain. All 999 response centres and ambulance services have categories which determine response times. A category one should arrive within seven minutes, category two within 18 minutes, then category three and four are two hours and three hours respectively.
At first I held back, not knowing what was expected of me. I didn’t know where to stand or what, as someone with no medical training, I should be doing or seeing. However, I was soon beckoned in to observe. I started to notice what would later became a theme of the day, the effect of the green ambulance crew uniform on patients and their families. There was an immediate calm, help was here.
Calming the patient
Next up, another category one – more chest pain, associated with late stage cancer. Once again, there was noticeable calming of the patient and their symptoms as help arrived. As with the first patient, we also took this patient on to A&E. I noticed the support that ambulance crews give to families and carers, as well as to the patient. They reassure and answer questions. They are a much-needed shoulder to cry on.
Later we were called to transfer a patient from a specialist eating disorder centre to a paediatric high-dependency unit. Here I noticed the importance of the immediate bond formed between patient and crew. Treating the patient as a whole person, not just a list of symptoms to triage. Within seconds of arrival, as well as assessing the patient’s physical symptoms, the crew will also start to build a relationship. In this case, it was vital that an emotional bond between crew and patient was formed. This was required to gain the trust needed to treat physical symptoms.
Throughout the rest of the day, I was astounded by the equality of care that every patient received. On reflection, this seems obvious, but I realised how demanding it is to be constantly tolerant, never showing stress or tiredness.
Gaining insight
I spent the rest of the shift trying to understand what a typical shift looks like for paramedics. This vital context, alongside all our other observations and interviews with a variety of other urgent and emergency care professionals, gave us real insight into what our users need.
We found out that paramedics do need access to service information. Above all, this needs to be quick and easy. They need to trust the tool they're using implicitly, and that means that the information it provides has to be complete and correct. They need to get access to hard-to-find information about mental health and social care. Lastly, and most fundamentally, they need to have complete confidence that the referral they are making will be successful, so that they can fulfil their duty of care.
The first option moving forwards from this research is the development of a responsive web app. This will allow access to the DoS for pharmacists and paramedics – initially in a private beta. This will enable greater awareness of local services appropriate to patients’ needs, as well as being easier to use than existing solutions.
My final take-away from the shift was that there is a fundamental need to build and maintain relationships between NHS Digital and frontline services. Researchers must be allowed in, so that we gain insights that ultimately help them do their jobs. The crew I observed were initially hesitant around me. They are used to student nurses and paramedics sitting in my place. For the first time (to them) ‘someone from the offices’ was taking an interest in their work – and, by the end of the shift, they were proudly showing me around the ambulance, asking questions about the project and being keen to help as much as they could.
