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The acute work of the ambulance service is of two sorts. Emergencies result from 999 telephone calls usually made by members of the public. Urgent transfers follow a request by a general practitioner (GP) or other health care professional to take a patient to hospital. In recent years there has been a large increase in emergency calls to the ambulance service. This has not been associated with a reduction in severity of illness, as judged by patient disposal from the A&E department.1 We felt that some of the increasing emergency calls was caused by a reduction in urgent calls and tested this hypothesis by examining the workload of the Westcountry Ambulance Service for each financial years 1994/5 to 1999/2000.
Emergency ambulance calls increased by 59.4% from 79 031 in 1994/5 to 125 161 in 2000/1 and in the same time urgent calls have decreased by 8.5% from 59 118 to 54 007. Urgent calls fell from 42.8% to 30.2% of the total acute workload. The increase in the emergency calls as a proportion of the total calls year by year was compared by χ2 testing. This yearly increase is statistically highly significant except between 1997/8 to 1998/9. These results are shown graphically in figure 1.
You would expect a rising emergency workload to cause an increase in both 999 calls and in calls to the GP that would result in more urgent transfers. This has not happened and it seems that there has been a transfer of some work from the GP services to the ambulance service. Some 10.9% of the increase in emergency calls can be accounted for by a decreased number of urgent calls.
We have not investigated the reasons for this change in practice but emphasis on the early recognition and treatment of severe asthma, myocardial infarction, and meningococcal disease may have prompted patients to call for an ambulance rather than phone their GP.
Another factor may be changes to the GP contract in 1995. GPs no longer have to visit all who call but can use their clinical judgement and can telephone for an emergency ambulance without seeing the patient or can advise the patient or carer to do so. In particular, the change in contract has stimulated the growth of GP cooperatives to cover out of hours work. These have resulted in a shift away from home visiting towards telephone advice and patients visiting the cooperative’s base.2 NHS Direct did not start in this area until March 1999 and so does not seem to be an important factor.
Much of the transferred workload may be justified but it has a cost. For the ambulance service, urgent calls have to arrive at hospital within half an hour of the time specified by the GP whereas emergency calls have to be responded to within eight minutes if category A and 19 minutes for category B. Emergency patients need to be assessed by a paramedic whereas for urgent calls, much of the assessment will have been done by the GP. For the hospital, patients arriving as a result of urgent calls will be seen by the admitting team. The same patient arriving as a result of a 999 call will need to be assessed by an A&E doctor before referral to the admitting team and this is putting additional pressure on A&E departments.
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