L'Ombre de l'Olivier

The Shadow of the Olive Tree

being the maunderings of an Englishman on the Côte d'Azur

02 July 2009 Blog Home : July 2009 : Permalink

Why "Free At Point of Need" Doesn't Work

Dr Crippen has a post about how ambulance personnel convinced a little old lady to refuse to go to hospital. The story as recounted by Dr C sounded very familiar, which is interesting as it tends to move my story beyond the level of anecdote, and various commenters at his blog have noted that paramedics all over the UK quite often do the same thing.

But I'm not going to criticise the amulance folks here because one of the commenter's explains the problem the Ambulance folk face:

Paramedics do not consider themselves to be doctors, I know I don't. However, for various reasons, mostly related to ridiculous government target setting, most of our work is non-emergency as in the case you have described. People have cottoned onto the idea that if they go to A+E they will see a doctor in 4 hours or less, and that if they call an ambulance they will get there for free.

As a result we are spending 90% or more of our time doing a job we are not trained for. The emergency jobs we are mostly good at are few and far between, and we spend our days going to people with flu-like symptoms, cut fingers and toothache. People who need no intervention, self medication or their GP. We do our best, trying to decide which of these is ill enough to go to A+E. Mostly we get it right.

We can't take everyone in, the emergency departments would implode - often they are unable to cope already with the flood of inappropriate cases.

So what we have here is another example of how incentives (or lack thereof) lead to unintended consequences. Since the emergency services are free and since A&E are required to see patients within 4 hours there is a major incentive by the not terribly ill to see if they can't get treated via Ambulance/A&E instead of jumping through the hoops of red-tape, paperwork etc. that are required to get treatment via one's GP.

Of course some people (e.g. my parents, the old lady in Dr Crippen's tale) are not timewasters and wouldn't dream of calling an Ambulance unless there was a serious problem, but the paramedics who show up have no idea whether they are or not. Worse, the sorts of people who don't abuse the system tend to be modest self-effacing sorts of people. The sort who apologise for being ill when they call the doctor and who tend to minimise their suffering when they do. They say things like "I'm a little under the weather" to describe hours of agonizing pain and the like.

Given all this it is clearly hard for the overworked amulance crew to figure out whether the person they've been called to see is a) a lazy malingerer or b) a meek but genuinely ill person. Hence sometimes they will misclassify people. And of course since they are busy, overworked etc. and because type a) is apparently far more common than type b) their incentives and experience means they are far more likely to work on the assumption that their patient is a type a) waste of time and react accordingly unless it is clear that their patient is genuinely in need.

And all this is caused by the fact that the NHS is paid for by taxation and not by individuals when they need it.

Now you could almost certainly fix this situation by charging people for wasted emergency calls. I can think of two ways to do this, neither is perfect but both would almost certainly drastically lower the load on the ambulance services and A&E departments. The first way is to send a bill later to patients who are deemed to have wasted the service, the second is to simply require an upfront payment before the ambulance arrives (and on entry to A&E for those not coming by ambulance) for those cases when the referral is not from some recognised authority. In both cases a lot of people would whine extensively and hence I suspect this is not an idea that any politician will dare to implement but I bet that if it did you'd see a massive reduction in the load on the NHS. One could also do the same with GPs and specialists (charging people for missed appointments) and see the load drop there too. The amount need not be the total cost of the service, it just needs to be high enough to cause potential abusers to reconsider.