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London calling

I don't know what I don't know about the NHS.  I think there's an awful lot I don't know, despite having edited a commissioning magazine for four years now. This unknown zone in my brain started glowing at the NHS Confederation conference a couple of months ago.

I heard a presentation by Dave Whitmore of the London Ambulance service.

I admit I was in a ‘conference mode' ie checking my Blackberry, when Dave first came on – our readers are GPs or managers not paramedics.

And then Dave made my ears prick up by saying the following: Only 20 per cent of cases the ambulance service sees are ‘trauma', that is the patient is unconscious or badly injured and so not in a position to say ‘can you take me to hospital A rather than hospital B please.' For the other 80 per cent, the choice agenda comes into play. Some patients are very vocal about their choice but what the London Ambulance Service has set out to do is to create a system that teases out from the more mute patients what it is they want the ambulance service to do for them.

The seed for this idea came from the case of a mother who wanted to give her son, who had severe epilepsy, the best possible chance of getting into school and integrating into school life. He was on the drug paraldehyde but the teachers were not prepared to give it and ambulance crews very rarely came across it. The mum had been to the doctors, the school etc, but no-one was prepared to help her. Dave arranged to meet with the mother and doctor to work out what could and couldn't be done for the child, get it written down in an agreement to tell the ambulance crews what they could and couldn't do and got it signed by the ambulance medical director, the mother and the doctors so everyone knew what could be done. Two years on, some 5,000 of this protocols have now been created, including some 660 end of life patients with a huge variety of medical conditions, including 100 paediatric cases. Each protocol takes about 4 hours to put together. A message flags up in the control centre when there is a call made from a designated number that a protocol exists and the crew in the ambulance can then see what choices the patient has stated prior to the call being made.

But what really struck me about this case study was that until now I've only thought of GPs as the ‘gatekeeper' of which providers patients are sent to. This case study makes me realise that there are 80 per cent of ambulance calls that are also involve a choice.

The driver for these ambulance protocols has been patient choice, but the opportunities for GP commissioners are massive.

Despite how much effort GPs put into redesigning pathways and engaging new providers if the ambulance service just takes them to the local district every time the trend will not be bucked.

I've come across one case study so far where GP commissioners have spoken about engaging with the local ambulance service. One.  

How many hospital admissions could the ambulance service help avoid? How much money could commissioning groups save by their patients not going through the doors of casualty? I don't know – but I think someone should find out.