I’m going to tell you a horrifying, but also a tedious and
frustrating, true story. It’s all about trying to get an ambulance to transport
an elderly man with dementia detained under the Mental Health Act from a care
home to a hospital.
The fact that the hospital is a private hospital 100 miles
away from the care home should be immaterial…
What ought to happen when a person, any person, is assessed
under the Mental Health Act follows a particular routine.
1. Arrangements for the patient to be
assessed are made. This includes notifying the bed managers that a bed may be
required, and arranging for two doctors, at least one of whom must be Sec.12
approved, to attend with the AMHP.
2.The assessment takes place.
3, A hospital is identified that will accept
the patient.
4. Arrangements are made for the patient
to be conveyed to the hospital. An ambulance is usually the most suitable mode
of transport.
5, The patient is conveyed to hospital and
admitted.
The chronic nationwide shortage of psychiatric hospital
beds, in our area especially for people with dementia, is now routinely meaning
that the assessment process is suspended after step 2. It can be days, or even
weeks, before a bed can be found and admission arranged. It is now very common in
our area for this particular private hospital to be used almost as an
additional ward for our local dementia patients.
This hospital often visits the potential patient before
making a final decision, which can take several days in itself, and if the
patient is fortunate enough to be considered suitable, the hospital requires
that they be admitted before 13:00 hrs on the day of admission.
But even once a bed is identified and the patient can be formally
detained under the MHA, we have been encountering problems with the local
ambulance trust.
Where a patient is in a care home, and the receiving
hospital requires admission before 13:00 hrs, it makes sense to order the
ambulance in advance, the previous day.
That’s where our AMHP hub first encountered problems.
It was my job as the duty Practice Consultant (see my
previous blog post for an explanation of what a PC is) to ring the ambulance
service and order the ambulance.
However, I was told in very clear terms that the ambulance
service was an emergency service, and could not be booked in advance. They
could only dispatch an ambulance on the day, using the “traffic light” protocol
agreed between the AMHP service and the ambulance service.
Briefly, this arrangement prioritises the response times. A
“red light” means that the patient is seriously distressed, the situation is
critical, and they need to be taken to hospital as soon as possible. The
ambulance will try to arrive within 30 minutes.
An “amber light” means that the patient is less distressed,
and the ambulance will endeavour to arrive within two hours, while a “green
light” means that the patient is settled and in a safe place, and the ambulance
will then arrive within four hours of being
requested.
Generally, this system works well, although even for “red
light” requests, ambulances can still be diverted to more urgent calls, such as
cardiac arrests. I can’t complain about this.
I pointed out that, as it was a “green light” request, if
the AMHP service made the request at 08:45 hrs, at the start of the working
day, if the ambulance did not arrive for 4 hours, then it would be impossible
for the ambulance to get the patient to the hospital before the admission
deadline, as the journey would take at least two hours.
But the ambulance service were not to be swayed, as the
request was not within what they were contracted to provide.
In the end, my PC colleague who was on duty the following
day had to ring the ambulance service from home at around 07:30 hrs in order to
ensure that the ambulance would arrive in time to transport the patient the two
hour journey to the hospital. In the event, the ambulance arrived at 10:45 hrs
and dropped off the patient at the receiving hospital 5 minutes before the
admission deadline.
This was clearly an untenable situation, so our AMHP hub
manager spent several days negotiating with the relevant Clinical Commissioning
Group (CCG), who actually make the contracts with the ambulance trust, as to
how this sort of situation could be avoided in future.
By the time I was duty PC the next week, an agreement had
been reached.
The CCG contracts manager gave instructions that we were to
ring a different number when wishing to arrange an ambulance in these
circumstances. This was the number of the patients booking line. These
ambulances were part of the local ambulance trust, but this particular service
allowed routine booking of ambulances to transport patients in a range of
situations.
As it happened, another patient was in identical
circumstances, so it was again my job to arrange for an ambulance to convey him
to the same hospital by 13:00 hrs the following day.
I rang the number, explained that the CCG contracts manager
had told us to do this, and requested an ambulance for 09:00 the next day.
The call handler was non-plussed. He went off to consult
with several different people during the course of the call, before finally
giving me not one but three reasons why they could not or would not convey this
patient.
Reason #1 Their service was not contracted to convey
patients detained under the Mental Health Act.
Reason #2 As both the hospital and the care home were
private, this meant that the patient was not an NHS patient, and they would not
in any case transport such a patient. (The fact that the hospital was being
paid by the mental health trust/CCG, and hence the NHS, to receive and treat
the patient appeared to make no difference).
Reason #3 Even though their contract was with a CCG that explicitly
covered the town in which the patient resided (it was in the name of the CCG),
they didn’t actually, really, cover that area, as it was in another county.
So I rang the CCG’s contracts manager and explained the
difficulty I was having. She suggested I spoke to the contracts performance
manager in the mental health trust.
I spoke to this officer, who admitted that there appeared to
be a gap in the contract, and told me to leave it with them.
Somewhat to my surprise, an hour or so later I received a
phone call from another call handler at the ambulance booking service. He took
all the necessary details of the transport request, including his current medication
regime, the fact that he was being prescribed lorazepam 4 times a day, and the
fact that he was frail and would need wheelchair transfer. It was arranged that
the patient would be collected from the care home at 09:00 hrs the following
morning. I was even given a booking reference number.
Success at last! Sanity had prevailed!
Ah. An hour later I received a call from the patient
ambulance booking manager. They had discovered Reason #4: their service was not contracted to take sedated patients. We would therefore have to make a
request tomorrow morning.
So it was again left that my colleague the next day had to
make an early morning phone call to the usual ambulance service number.
They initially tried to give a Reason #5 why they could not transport
the patient. This was on the grounds that the hospital, being in another
county, was outside the area they covered. However, this was withdrawn when it
was pointed out that the ambulance trust covered a very large geographical area
which explicitly included the county in question.
They didn’t seem to be able to come up with a 6th
reason, so eventually an ambulance crew picked the patient up and took him to
hospital within the required time scale.
What’s the
significance of this in the wider scheme of things?
This sorry failure to
meet what would appear to be a straightforward request exemplifies a far deeper
problem in the NHS: privatisation by
stealth.
This has been
happening gradually for many years. It goes all the way back to Margaret
Thatcher’s government in the early 1990’s, which brought in the NHS &
Community Care Act 1990. Among other things, this introduced the concept of the
purchaser/provider split in the provision of social care, which was explicitly
designed to encourage the use of private services. Whereas before, home care
was provided in house, the Act required at least 80% of home care to be
purchased from private organisations.
In mental health, NHS
trusts have been operating under various guises for many years, opening the
way, at least in theory, for trusts to compete with each other in an internal
market to provide services, while the introduction of clustering and “payment
by results” in 2013 made it possible for packages of care and treatment for
mental disorders to be “sold off” to private companies prepared to offer
specific services. I discuss this in more detail in this blog post.
The Health and Social Care Act 2012 disposed of Primary Care Trusts and replaced them with
Clinical Commissioning Groups, supposedly led by clinicians, whose function was
to purchase services from NHS Trusts – or indeed, private companies prepared to
offer these services. Companies such as Virgin Care have stepped in and provide
a range of health services, relieving the NHS of billions of pounds in the
process.
Apart from these
private health care companies, there is now a well-established internal market
within the NHS. While ostensibly this is designed to facilitate provision of
services, in practice this does not necessarily happen. The example I have
given highlights the problems with this artificial division of budgets.
The problems I
encountered in obtaining transport for a detained patient are entirely due to
this bizarre internal market. The local Ambulance Trust, which is of course
part of the NHS, has a range of contracts with the Clinical Commissioning
Groups within its area.
These contracts are
not necessarily to provide a blanket ambulance service, but are written in such
a way that very specific services are offered, and if a request does not fit
with the wording of the contract, then the service will not be offered.
It has
long been established that the local ambulance trust will not convey patients
out of its area, and will not convey patients requiring restraint. The AMHP
service then has to rely on private ambulance services, at huge expense to the
CCGs.
Another local
example of what would appear to be a nonsensical interpretation of a contract is
that the local ambulance service will convey a patient detained under
Sec.135(1) to a place of safety for the purpose of assessment, but if the
patient is then detained under the MHA
and needs to be conveyed to a hospital, this transfer is not covered by the
contract.
It is difficult to
understand how this system is of benefit to patients, and how it might save the
NHS money.
