Death Rate to Increase in London – and – The Medicare Tomato

Howdy everyone!

I’ve read some things out there on the interwebs lately that I’d like to share with y’all. These are articles that made me think. They also made me feel a certain way after I read them. Individually, they would have been interesting on their own merits. However, when read together one after another, I think they do something to your brain that you should experience.

And let me just say, good luck with this.

First off, I read this post by Rogue Medic that linked to this post by entitled “Death Rate in London to Increase”.

As always, Rogue Medic has provided his genuinely valuable insight to the article and I am very much glad he called it to our collective attention. I suggest you read the original post first and then read the Rogue’s interpretation on it. While you’re at it, be SURE to read each and every one of the comments on Mr. Kellet’s article. Read them all, it’s very telling.

Including this one:

"560 frontline cuts is a huge number and your comments with regards to little yellow cars is spot on. Time to start investing in private healthcare company shares perhaps."

Uh huh.

It looks like the London Ambulance service is cutting 560 paramedics from their staff, decreasing available ambulances, and is shifting the focus to Rapid Response cars with a single-medic. While these cuts would be common-place in American cities these days (except of course, for the Rapid Response Cars); doesn’t the NHS support the LAS? Wouldn’t they be fully reimbursed for their care? I thought they had a well-funded healthcare system over there across the pond. 

Then read this fascinating look at universal healthcare written by The Happy Hospitalist and posted on his site about a year ago: The Medicare Tomato – It is just an absolutely fantastic article that you need to read, now.  If you’re not convinced, read this quote from the piece:

“A consumer came in today at 12:04 pm on March 7th, 2008. He did not complain of any tomato headache. He had no gas pains. He appeared to be in good spirits. He was not orange. His lips were drooling for a chance at free tomatoes. He appeared angered at the lack of options and declining quality. He was at one point found to be pointing and yelling profanities. He took 7.4 pounds of the super duper genetically altered tomatoes (verified by government scales) with a big fat giant grin on his face, yelling, "I ain't paying for it", all the way out the door.”

This guy’s one of us.

I’m withholding comments of a political nature right now. While I have strong feelings on the looming changes in US healthcare and the economy in general, I want to foster the discussion and see a broad cross-section of opinions in the comments section. I want to know what y’all think.

However, if you would like to read some of my articles on what my opinion is, feel free:


I’m not picking on my British EMS brethren here. I like the boys in green quite a bit, like my friend Insomniac Medic and @ukmedic999. To prove it, here’s some of my writing on the whole UK thing and how it’s good, too.

A Shoutout Across the Pond to our British EMS Brethren

  • Rdwtc3

    Another idea would be the creation of a hybrid system:  keep traditional EMS (ALS and/or BLS), and augment the reduced number of ambulances (possibly reduced by as much as 50%) with advanced care paramedics, the latter working singly in standard automobiles. Allow all levels of EMS to bill, moderately, for assessment and on-scene treatments. 

    I did say “reduced number of ambulances.”  I have been working in this field for five years, and based soley on my observations, the number of EMS transports could be halved.  With true research, it might be that my numbers would require some adjustment, but I would bet they are not far off the mark.  If the paradigm of treatment/transport options mentioned in this article are followed, we could probably reduce the number of ambulances on the streets by half.  EMS crews working as 911 providers also need the legal abnility to say “No.”  When called to a home at 0300 for discomfort due to a diagnosed sinus infection simply because the patient cannot sleep, EMS providers, with consultation from medical control as appropriate, need to be able to say, “No, we will not take you to an already overcrowded ER by ambulance for your complaint.”  And then this patient should be billed for the assessment.  Contrary to the common knowledge of EMS, you CAN fix stupid, at least sometimes, by making it pay cash for its act of stupidity.

    The real problem with this paradigm is that in many locations, after 2100 each day, options for treatment are rarely more than, “which hospital do you want to go to?”  When I read the NHTSA EMS Agenda for the Future, my response was that there were some wonderful ideas within it, but to try to make EMS do the work of multiple levels of healthcare and social service agencies without a DRAMATIC change within those agencies themselves is utter folly; it’s a classic concept of the tail wagging the dog.

     You skipped the step where dispatchers would have to be better trained to screen for the appropriate level of response.  Maybe some of the EMTs who would become unemployed by the greatly reduced number of ambulances on the streets could be employed as triage officers in 911 call centers.  EMDs are great, but why utilize them when an EMT could  better assess the patient, even by phone.

    The final step in this process is going to cost money: END 24-HOUR SHIFTS.  This stupid practice is unsafe and only helps employers.  All EMS should work 12 hour shifts, with a minimum of 10 hours off between ALL shifts, and work 36 hours one week and 48 the following week, gaining overtime pay for hours worked in excess of 80 in a two-week period.  Workers should be assigned to days or nights permanently, with the ability to bid the opposite as positions open.  There would be some savings here, in that we would no longer need stations with sleeping quarters, but it would require 25% more personnel to fill the open shifts, and EMS personnel, in many cases, would earn the same pay for an average of 840 fewer hours per worker per year.  Why should we be perceived as professionals when the people doing our jobs are often on duty for 2/3s of their lives? 

    We need a revolution in EMS; it’s time to alter the experiment.  Tradition is a wonderful thing, except where it obstructs progress. 

  • Andy

    The problem we are facing in the UK is that the NHS budget has been cut by a massive amount. These savings have to come from every part of the system, so London, like the rest of us has to make less money go further.

    The reason why we need so many ambulances in the UK is because a, we have to transport a patient if they insist, even if we think they don’t need to go. B, the registering body for paramedics here, the HPC are far too trigger happy and blame paramedics for things that are often beyond their control or happen days after they see the patient, often striking them from the register which breeds the ‘you don’t get sacked for taking them to hospital’ culture. C, paramedics in the UK are registered and autonomous practitioners with no online medical control, so have no one to turn to beyond more senior paramedics or emergency care practitioners for advice, meaning that it’s your neck on the line and no one else’s.

    Also, we already operate a large number of single crewed response cars, but they are used predominantly to get to incidents quickly and meet the government mandated targets, often they are backed up very quickly by am ambulance, and only spend a few minutes with a patient, usually just enough time to complete a set of baseline observations then move on to the next call, leaving the patient with the ambulance crew to continue care.

    Add to that that all health care is free at the point of delivery, and the stupid, jobless and ignorant will use us as a free taxi to get to hospital. In fact I’ve had patients tell me that’s why they’ve called several times in the past, but again, we have to grit our teeth and take them.

    Charging even an inconsequential fee would be detrimental because the truly vulnerable and genuine medical emergencies would suffer in silence and die due to fear of the costs and not being able to pay. As it is, I’ve been to an elderly patient having a heart attack that waited until after 8am to call because they didn’t want to bother anyone during the night, and similarly, another that didn’t know if there was anyone there at night(!) Imagine if they knew that say 10% of their weekly pension would be charged for service (£14) When they are already having to choose between heating and food to survive…..

    A BLS/ALS system wouldn’t work either because the BLS crews wouldn’t be able to leave patients at home after dealing with their illness/injury so an ALS crew would be required to assist them anyway, tying up two vehicles. Also in parts of the UK paramedics are paid the same as EMT’s so having BLS vehicles would cost the same as ALS vehicles in these areas. In areas where they are a pay band apart, the difference is only £5k per annum between an EMT on full pay and a paramedic on full pay.

    And with regard to weeding out junk calls, the are already systems in place to weed them out, but they only catch calls that are graded Category C in AMPDS. They don’t catch the stubbed toe who ‘isn’t breathing normally’ that becomes a Category A call because of this.

    Not to mention that these calls are assessed by paramedics in the control room who are also subject to the HPC and have their registrations to loose so will send vehicles to all but the most stupid calls to save their own skin.

    I genuinely don’t know how to reform UK EMS without damaging the care provided to at least one section of society. Clearly we can’t go on with ‘free ambulances for all!’ and carting everybody to the ED just because that’s what they want or think they need.

    • Ckemtp

      Excellent comment!

      Thank you, you made my day. This is exactly the kind of discussion I want to see.

      I wonder if the “nominal fee” could use the model employed by some US insurance companies and waive the fee (co-pay) if the patient is admitted or has a severe intervention. They pay if they’re discharged with no intervention needed.

  • Andy

    I try my best 😉 that sounds like a good idea, it’s not one I’ve ever thought of and much fairer than a blanket charge. Unfortunately, the great unwashed wouldn’t pay it, and our courts are too soft to enforce any kind of fine for non payment. If you get a few hours unpaid work for committing multiple thefts or burglaries then ambulance fines are going to be bottom of the pile.

    Perhaps they can provide us with a couple of new bits of kit, one is called judgement, and the other is called a pair of balls. The best thing is, they won’t cost anything! (sorry, it’s been a very long day!!)