by Lawrence Donaldson

Ambulance ramping at hospitals … a problem too delicious to solve?

The problem of ambulance ramping at hospitals across the country cannot be solved in the same way that you might solve a maths problem. It is probably better described as a ‘wicked problem’ – one that is complex, features contradictory analysis and seems to have no discernible resolution point.  That is to say, by the time you find the answer the question will have changed.  So yes, ambulance ramping is a ‘wicked problem’ but it’s also a ‘delicious problem’.   Why delicious I hear you say?

I think a delicious problem is one that serves the interests of too many influential people to  be solved readily. Simply put, too many people are getting too much of what they want out of the problem to permit a ready resolution.   After all we should never waste a good crisis!  A delicious problem gives us opportunity to grandstand,  achieve public notoriety,  pursue personal and professional interests and enjoy the drama of it all.

In this sense ambulance ramping is not so much the problem we have to have,  but perhaps more the problem we want to have -at least for now!  Yes, resolution is indeed possible but not until we acknowledge the reality of what’s actually happening.

This is a ‘strife of interests masquerading as a contest of principles‘!  There is a lot at stake for everyone including governments, politicians, hospital administrators, healthcare professionals, professional bodies, unions, policy makers and …. lest we forget…. the actual patients!”  Can you have your problem and solve it too?  No, you can’t!

The following article explores the nature of the ambulance ramping phenomenon, some of the less obvious root causes and how we might begin to resolve it. For the uninitiated ambulance ramping refers to those occasions when multiple ambulances are left queuing for significant periods outside of a hospital unable to off-load patients due to over crowding in the Emergency Department.  It has become emblematic of a health system in crisis-  the”canary in the coal mine” as it were!

How can people possibly benefit from ambulance ramping when it causes so much alarm and distress?

Health at times seems dominated by the politics and thinking of ‘more’.  This paradigm holds that all problems are essentially to do with a paucity of resources and therefore fixed by Governments tipping in more money.  In the case of ambulance ramping the calls for additional money is to buy;  more paramedics,  more ambulances,  bigger parking lots, more Emergency Department staff,  more hospital beds,  bigger EDs,  and so it goes.  This narrative is easy to understand and compelling for the public in general.  Check out this article as it illustrates the point.

We only have to look to the USA to know that more money won’t make for a better health system with better outcomes. In the US their health system consumes the highest proportion of  GDP of all developed countries but its outcomes are at best middle-ranking.  More resources might make for bigger and better careers and incomes for healthcare professionals and more prestige for institutions but we shouldn’t assume that patients will benefit.  We need to invest in a way that engenders sustainability not in a way that locks the country deeper into a spiral of unsustainable demand growth.  I recall a Hospital Specialist once saying to me that it was his job to spend the money and it was my job to find it – but that’s not how the world works.

Hospitals in Australia have been incentivised to grow with a significant proportion of their funding activity based. As one Melbourne Hospital Executive put it to me “the secret to future-proofing the budget is to see more patients year-on-year but with slight efficiency improvements”.  In this sense Hospitals are now victims of their own success with ambulance ramping evidence of this.  The budget woes of hospitals have been exacerbated with the Commonwealth’s decision to put caps on its contribution to State hospital growth funding.  Growth will no longer be rewarded as the policy agenda moves away from increasing patient access to hospitals, and more to managing demand,  ensuring that only those who really need to be at a hospital get through the front door.

The politics of a crisis in health is also ‘delicious’.  It makes the incumbent government a sitting target for criticism and ridicule.  I wonder how many have won election with the promise of fixing the ills of the local health system only to back-pedal when confronted with the intractability of health system change.

The politics are not only of the big ‘P’ variety. Hospital politics are every bit as a colourful as that in Canberra, as anyone who has worked in a hospital knows.  Over a decade ago I recall an ED head candidly sharing his main reason for not cooperating with a strategy to reduce congestion in his treatment rooms.  He said that having a busy and over-stretched clinical department was absolutely vital to his internal political leverage.  Any sense of being over-resourced would see competing clinical heads immediately clamouring for the transfer of his budget and staff to their ’empires’.  A busy ED was also thought essential to retaining the department’s accreditation for the teaching of its ED registrars-  these specialists-in-training need patients at volume to learn their craft.  The ED head felt that if his department was not growing it would contract by default and as such he felt it imperative to secure as much patient demand as possible – hence his unwillingness to work with local GP practices to reduce the increasing numbers of  ED patients whose needs could be capably and safely met in a GP setting.  Clearly there are a range of drivers affecting the behaviour of key stakeholders and these need to be understood if we hope to deal with them.

And what about the media?  Crisis in health makes for easy and dependable ‘copy’ in the printed media and electronic news feeds.  It would be great to see our talented journalists deploy their considerable skills in helping the public better understand the nature of the problems we confront in health and our shared interest in achieving sustainability. I recall another occasion when a Hospital Professor gleefully told me about his ability to manipulate the media to help secure outcomes he sought with the State health bureaucracy. While I did not condone his behaviour I could understand it.  He felt that his skills in manipulating the politics of the situation were every bit as valid as his immense clinical expertise.

To be fair not everyone feels the need to play politics or thinks money will solve everything. The Monaghan Review from 2012 into ambulance ramping in South Australian hospitals is an example of an objective, nuanced and sophisticated analysis. His review had 55 recommendations including some designed to address inherent inefficiencies in hospital processes along with  the removal of artificial professional demarcations which were both very significant contributors to the ambulance ramping phenomenon.  Clearly,  injecting more resources will not in itself fix patient flow inefficiencies and it could in fact make things worse.

A nuanced conversation is required that considers a complimentary mix of the changes required:

  • Yes, more funding to boost capacity in the short term while complimentary structural changes can be planned and implemented
  • A review of internal hospital processes to consider opportunities to improve patient flows  e.g.  dealing with bed-block and discharge-block
  • Removal of artificial industrial demarcations that prevent ED staff from working at their ‘top of license’
  • Introduction of new workforce typologies such as Nurse Practitioners in the Emergency Department setting -e.g. Extended Scope Practitioners
  • Systematic integration (i.e hard-wiring ) of the care being jointly provided by GPs and hospitals to people at known risk of frequent hospitalisation.  Ask any GP and off the top of their head they will be able to list their patients at high-risk of an unplanned hospital stay.  We should be using this intel !
  • Systematic and proactive support by Hospitals (including EDs) to the frail elderly living in residential aged care facilities.  Ask those working in RACFs and they will provide plenty of examples of residents being transferred inappropriately to the local hospital.  The last place that a frail elderly person needs to be is a hospital ED unless it’s absolutely necessary!
  • Better sharing of  consented patient records – e.g. the My Health Record

I am sure that others could readily add to this list and we should acknowledge that there are examples around Australia where these changes are already being pursued.  The potential for transformative change comes when reformers look to apply a locally appropriate mix of selected initiatives designed to be mutually reinforcing. It is this purposeful alignment that creates the change momentum. To unlock the potential for change we need to think of it less as a padlock and more as a combination lock!

The missing part of the conversation- managing patient demand!

What seems to be deficient in the national discourse is the importance of managing patient demand to ensure that only those who have an acute healthcare need are presenting at EDs – whether it be by ambulance or as walk-ins.  I appreciate that this is controversial with those of the view that the public has a right to attend a public hospital emergency department as they see fit and should expect to be seen in a timely manner regardless.

There are others of the view that a society can always produce more ill-health than a country can afford to treat and as such would agree that the public very much needs to be engaged in a respectful and meaningful discussion as to what role they can take in de-congesting over crowded local EDs and Hospital wards. After all, members of the public rely on hospital services but also pay for them as taxpayers.

In my view the avenue of demand management is yet to be fully explored in addressing ambulance ramping and related over-crowding in the hospital wards.

Things that can be enacted quickly to reduce ED demand safely and appropriately include:

  • Targeted mass Flu immunisation campaigns for high risk groups such as the frail elderly and those with complex chronic conditions (the recent shortage of the Flu vaccine will put the kibosh on this for the 2018 winter unfortunately)
  • Community education campaigns about the role of Hospital Emergency Departments- especially in the after hours period. I know many PHNs nationally have been trying to engage their hospital networks in this
  • Joint initiatives between Hospital EDs and After Hours GP Service providers
  • Triple 0 Ambulance diversion of low acuity callers to alternate healthcare providers especially in the after hours period- refer to the Victorian Ambulance Secondary Triage Service Initiative . There are GP practices that would be happy to be part of an ambulance diversion strategy providing the patients referred to them were appropriate for their scope of practice and a “warm-transfer” was undertaken.  The beginnings of GP over-supply in some of the capitals makes this possible and attractive to practices looking to establish a clientele.

Things that would take longer to implement but promise to be more impactful include new service models such as:

No doubt there are many other innovative service models under development that can help alleviate ED and hospital congestion by improving the integration and the resultant quality of care.  Your Primary Health Network will have a good appreciation of local innovation in service models.

If you have presided over and benefited from the current system are you likely to be the one to reform it?

One of the impediments to resolving health system problems is that the conversation feels dominated by insiders and it is unrealistic to expect that those who have presided over the current arrangements for decades will always be amenable to reforming them. It takes great generosity of spirit and moral courage to “plough-over” your turf  so that your successor can grow something different.  In my experience hospitals are highly traditional and conservative institutions which look askance at unproven change.  This is the paradox of system innovation- you don’t have the evidence of success until you actively create it and not everyone has the same reform ‘appetite’.

The Australian public has had its eyes opened to the scandals of other  previously unimpeachable institutions such as the Banks and the Churches.  Hospitals are led by people just like you and me, capable of the most amazing acts of service to others as well as the most venal self-serving acts. We are not saints although we all tend to rush to the moral high-ground when we feel threatened.  (My high-ground is so high I routinely suffer from nose bleeds!)

We all have interests and worldviews shaped by our circumstances and life experiences and this is nothing to be embarrassed about.   It is incumbent however on those charged with leading reform to ensure that these often conflicting interests and worldviews are understood sufficiently so that their influence on decision making is more transparent.

Conclusion

Please, let’s be clear about this! We can work to reduce ambulance ramping and reduce the congestion in Emergency Departments and hospital wards but it will take great leadership by politicians,  government bureaucrats, policy specialists, hospital administrators, hospital clinicians, GPs, allied health professionals and community leaders – working together with system reformers.   Pragmatism and compromise will be required and at times we will be challenged to subordinate our own interests for the good of others.

The problem of ambulance ramping might be ‘delicious’  but as we all know the things that we find most delicious are not always best for our health! 

We and our loved ones rely upon a local hospital with an emergency department that we can have confidence in.  No-one wants to be stuck on a stretcher in the back of an ambulance waiting in a long queue to get the care they need.  This transcends the narrow interests of the few and we should be assertive in pursuing something better.

Important also is the need to support those healthcare professionals who are in the front-line, those shouldering the daily burden of impossible patient loads.  They deserve better as well.

Please leave a comment to add to this important conversation.