“RTB for a cuppa” I’m allocating in the UK

chroniclesblogRTB means Return to Base.  A cuppa is slang for a cup of tea.  Allocating is something I very much wanted to see first hand.

On this morning in Newcastle, my second to last, Mark has arranged for me to meet with the executive staff of the NEAS at their headquarters.

Before meeting with them, however, I’m downstairs in the bullpens.  I’ve got 2 hours to sit in the dispatch center and do a “Sit-along.”

When you tell a guy who loves talking theory on systems allocation he gets to see the system work from the nerve center, he gets a touch giddy.

My first chair was at a call taker’s desk and I got plugged in.

BANG, less than 10 seconds, not even a chance to introduce myself to the call taker I’m with the first tone is in my right ear.

Before she can answer the call a timer has popped up on her screen 8:00, 7:59… the clock is running.

“Ambulance Service” she answers and begins reading from the screen the pre-ordained triage system called Pathways.  As I’ve mentioned before, this dispatch system makes no attempt to diagnose the problem, but the physician designed questions can dial up or down the response in real time as the call taker asks the questions.

While she is asking and answering, a small red circle has appeared on the screen, then, a bit away, a purple one.  Later I would learn that one is the location of the caller and the other the closest vehicle assigned to the call.  When that vehicle arrives on scene, the timer now passing 6:15 will stop.  This is their target and they take it very seriously.  As I’m listening to the call, it is a very straight forward sick call and the caller is honest about it.  It is then I see the benefits of the flexible front loaded system.  The rapid response car, the closest resource to the caller, has been stood down since there is not an emergency at the caller’s location.

The vehicle, or cot transport capable ambulance, is continuing, however, and the target is no longer 8 minutes, but now 16 from the time the call was answered.

As more questions are answered and the system confirms the lack of life threats, a simple screen gives instructions for the caller until the crew arrives.  The call taker then scrolls around her GPS monitor and finds the vehicle, then advises the caller about how far out they are.  The caller thanked her and the call was terminated.  Less than 3 minutes passed from the answering of the call to the triaging and confirmation of appropriate response.

At no time did a supervisor step in to augment the call taker’s classification, nor did the system err on the side of caution by upgrading the response, putting rescuers’ lives at risk, “Just in case.”

In the hour we were together I learned more about the desk I was at and the number of calls she answers in an average shift.  We took mostly non-emergent calls, details of which would obviously violate privacy, but I can share with you the CALLERS.

When I explained how folks abuse our service by calling from a cell phone miles away about a person they think might have been either unconscious or sleeping, she smiled.  Then, I went on, our criteria based dispatch system considers the caller’s inability to confirm consciousness to be unconscious and their inability to confirm breathing to be apnea, and 7 people are now responding code 3 for nothing.

It was just when the call taker was explaining some of the loop holes used that a care facility called to request an ambulance.

They were not with the patient so unable to observe their mental status, efficiency of breathing or if there was any bleeding.  The system took this information and kept the RRC responding.  Each time the call taker asked a question, the caller was already answering, knowing exactly which question comes next.

She later explained that folks have learned that if they take a cordless phone around the corner and call an ambulance, the crew arrives faster than if they honestly answer the triage questions.

“Same callers, different country.”

It was later in the morning across the room with the allocators that I saw the strength and weakness of the NEAS.

Mark and I spoke at great length about being honest but respectful when offering our observations and suggestions to improve each other’s systems.  Mark was an example of this when he met with SFFD Chief of EMS Pete Howes for a kind of exit interview before leaving.  I hope I can meet that example with the following paragraphs, but each time I write it it comes off preachy, so here goes.

Sitting between the allocators I watched them constantly on the radio with numerous vehicles and cars in various states of service.  Each color on their screens meant something different, from enroute, on scene, RRC, vehicle, on post etc, but it was the clipboard they were passing back and forth that caused them the most frustration and, more than once, delayed allocation.

Not by a definitive amount, we’re talking 3-5 seconds, but it was the constant flipping of pages and radio traffic related to the one thing that I think the NEAS needs to change for the betterment of the system.

No more breaks.

I can hear the UK medics now “Hell no.”

Let me elaborate for my work straight through the shift American friends.

The NEAS, as a portion of their labor agreement, provides their crews with certain breaks depending on their daily activities.  When they have been on post for an hour away from station, they get rotated back to the station.  This was commonly referred to on the radio as “Return for a cuppa.”  The basic premise is simple enough, really.  People need clean bathrooms and a chance to eat since eating is not allowed in the cars or vehicles, nor are they allowed to sit down and eat in an establishment while on duty.  This was evident when Mark was nervous enjoying some Pho in San Francisco.

In the car and vehicle this didn’t seem to be a big deal, we’d get a message to return to base, or that we were clear for meal break.  The meal break can be interrupted, should the allocators need the resources, but they avoid it since the crew interrupted gets paid quite a bit for it and the allocators, although they wouldn’t elaborate, appear to be held accountable.

Sitting between the two allocators on the desk that morning, 50%-75% of their time was arranging rotation station breaks or ensuring crews got their meal breaks.  These variables also added more color codes to the dispatch screen.  This car is on dinner, this vehicle is on base rotation…etc, etc.

When a call came in they shot a quick look to the clipboard showing who gets a break when and dispatch decisions are based off of that.  I did not witness it make a difference in response times, since that information is streaming in real time on giant monitors overhead, but these folks are scrambling to keep everything running smoothly.

With my limited dispatch experience it seemed like a simple change, since on the days I was on rotation in Newcastle we never had a point in the day where we were unable to reach a bathroom or food.

My head was trying to process all the information these women were basing their allocations on and one of them turned to ask me, inbetween moving a car back to base “for a cuppa,” “How do your dispatchers handle your breaks?”

When I explained we (listen to me, like I’m still in a rig), THEY are gone for 10 hours, no breaks, they froze.

It was passing the clipboard back and forth that I saw the only 2 seconds they both held still: glaring at me.  It was clear I was not to repeat that statement for the rest of my time with them.

“That would make, ‘Go ahead 405′ this so much ‘thanks and to base if you please’ easier.”

Yeah, 2 conversations at once.  I have trouble typing and listening to music or TV at the same time.

Mark had some family business to attend to while I was meeting the voice on the other end of the radio and he returned just before dinner time to collect me.  It was an eye and ear opening experience to see the chaos that a simple concept like breaks caused the folks moving units around.

Something I completely neglected to mention over lunch with the executive team.

Told you I couldn’t screw that up.  My conversation with the folks hopefully getting Mark cardioversion and CPAP, and where to put your coffee when the table is literally covered in signs that say “DO NOT PUT CUPS ON TABLE, USE SAUCER” soon.

Yeah I did.

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18 thoughts on ““RTB for a cuppa” I’m allocating in the UK”

  1. The medics I dispatch for currently do not have any break time written into their contract. We did do a 1 month trail, to investigate what it would look like if we gave the medics a 30 minute break, but let’s just say it did not work out very well and no one really liked it. During the trail there was an EMS Supervisor who was scheduling the medics for their breaks, but only when it was requested by the medic. Not many of the medics took advance of the break time, they said they were getting enough down time between calls, and while they were waiting in the hospitals for a bed. It was a logistical nightmare to deal with the breaks that were approved, and very difficult to keep optimal coverage for the city; it was a nice idea but very hard for use to put it into everyday practice.

    One of our dispatch SOPs is called the COOL DOWN SOP, basically it allow a medic to contact their supervisor and request a COOL DOWN (commonly called a break in the real world). COOL DOWNS must be approved by a supervisor, giving around the mid-point of the crews shift, and when a crew has not been free for a minimum of 1 hr. When a crew is granted a COOL DOWN, they are sent to a station with another free medic unit – this allows them to be protected from getting another call. COOL DOWNS are 30 minutes long, and a unit can have 1 per shift. Generally the medics don’t request a COOL DOWN very often. I can’t remember having to deal with COOL DOWN in the last 3 months.

    If the break trail was successful and breaks became everyday practice for us, the medics could have contacted their supervisor for a 30-minute break, and a 30-minute COOL DOWN potentially leaving then out of service for a break for 1 hour. That could have cause a big headache for dispatch because there are just not enough hours in the days to allow for every medic crew to have a 1 hour break when there are over 20 medics working during the peak day hours.

  2. The medics I dispatch for currently do not have any break time written into their contract. We did do a 1 month trail, to investigate what it would look like if we gave the medics a 30 minute break, but let’s just say it did not work out very well and no one really liked it. During the trail there was an EMS Supervisor who was scheduling the medics for their breaks, but only when it was requested by the medic. Not many of the medics took advance of the break time, they said they were getting enough down time between calls, and while they were waiting in the hospitals for a bed. It was a logistical nightmare to deal with the breaks that were approved, and very difficult to keep optimal coverage for the city; it was a nice idea but very hard for use to put it into everyday practice.

    One of our dispatch SOPs is called the COOL DOWN SOP, basically it allow a medic to contact their supervisor and request a COOL DOWN (commonly called a break in the real world). COOL DOWNS must be approved by a supervisor, giving around the mid-point of the crews shift, and when a crew has not been free for a minimum of 1 hr. When a crew is granted a COOL DOWN, they are sent to a station with another free medic unit – this allows them to be protected from getting another call. COOL DOWNS are 30 minutes long, and a unit can have 1 per shift. Generally the medics don’t request a COOL DOWN very often. I can’t remember having to deal with COOL DOWN in the last 3 months.

    If the break trail was successful and breaks became everyday practice for us, the medics could have contacted their supervisor for a 30-minute break, and a 30-minute COOL DOWN potentially leaving then out of service for a break for 1 hour. That could have cause a big headache for dispatch because there are just not enough hours in the days to allow for every medic crew to have a 1 hour break when there are over 20 medics working during the peak day hours.

  3. Hello there Sir!

    I wonder if we look at this break issue a slightly different way?

    I can see what a nightmare it must be for our controllers and allocators to try and get all crews back to station and stood down for 2 x 30min breaks every 12 hour shift, I really can. In the past they had to get us back but we could be disturbed off our break for a Cat B or Cat A emergency, which was a very frequent occurence.
    At the time, we were paid during that break therefore we had to be available.
    Now, about 6 years ago, we stopped getting paid for our stand down periods (it was a way to get around getting out weekly shift hours down from 42 to 37.5). It now became a totally different ball game.
    If you were not getting paid, would you be available to go out on calls? Once the unions got hold of it, it became more of a union stand point that we all had to stick together on this, which then quickly became the norm and to be honest, the staff suddenly realised the benefit of actually knowing that they could cook a quick meal and actually eat it whilst hot!!

    As for ‘Little Girls’ system, I am assuming that it is quieter than mine. Although you saw a couple of fairly quiet days whilst you were here, that was not the norm.

    Tonight, I started at 18.30. I was out on my first job at 18.38 and I have just returned for my (late) meal break at 00:27. That was just job after job with no standbys.

    I bet most paramedics who work in fairly busy systems would like to actually have a rest a couple of times during their day (and I mean a proper rest, not just quickly grabbing something to throw down thier necks before the next job comes in), or am I wrong??

    Great post though – always good to see what you do from a fresh set of eyes.

    1. Mark, I really can’t compare our systems very well – I don’t know the details of your system.

      I dispatch for a fairly large metropolitan city (approx 1.5 million people), and an extensive rural area. My dispatch centre is one of the largest in the western provinces. I deploy more resources then Justin’s system, and we have some resources that are similar to your RRV.

      When we trailed breaks for our medics it was based upon a request from their union. It didn’t work this time around, maybe next time it will work.

      Also, if the medics are forced into non-paid breaks, they will say something about dispatch getting paid breaks and then the Unions will be fighting with the City & Government – it just won’t be a nice thing. 9-1-1 almost went on strike in my community this year, because of break time the was scheduled and non-scheduled.

      The Medics are an essential service while 9-1-1 Emerg. Officers are not considered an essential service.

  4. Hello there Sir!

    I wonder if we look at this break issue a slightly different way?

    I can see what a nightmare it must be for our controllers and allocators to try and get all crews back to station and stood down for 2 x 30min breaks every 12 hour shift, I really can. In the past they had to get us back but we could be disturbed off our break for a Cat B or Cat A emergency, which was a very frequent occurence.
    At the time, we were paid during that break therefore we had to be available.
    Now, about 6 years ago, we stopped getting paid for our stand down periods (it was a way to get around getting out weekly shift hours down from 42 to 37.5). It now became a totally different ball game.
    If you were not getting paid, would you be available to go out on calls? Once the unions got hold of it, it became more of a union stand point that we all had to stick together on this, which then quickly became the norm and to be honest, the staff suddenly realised the benefit of actually knowing that they could cook a quick meal and actually eat it whilst hot!!

    As for 'Little Girls' system, I am assuming that it is quieter than mine. Although you saw a couple of fairly quiet days whilst you were here, that was not the norm.

    Tonight, I started at 18.30. I was out on my first job at 18.38 and I have just returned for my (late) meal break at 00:27. That was just job after job with no standbys.

    I bet most paramedics who work in fairly busy systems would like to actually have a rest a couple of times during their day (and I mean a proper rest, not just quickly grabbing something to throw down thier necks before the next job comes in), or am I wrong??

    Great post though – always good to see what you do from a fresh set of eyes.

  5. Mark, I really can't compare our systems very well – I don't know the details of your system.

    I dispatch for a fairly large metropolitan city (approx 1.5 million people), and an extensive rural area. My dispatch centre is one of the largest in the western provinces. I deploy more resources then Justin's system, and we have some resources that are similar to your RRV.

    When we trailed breaks for our medics it was based upon a request from their union. It didn't work this time around, maybe next time it will work.

    Also, if the medics are forced into non-paid breaks, they will say something about dispatch getting paid breaks and then the Unions will be fighting with the City & Government – it just won't be a nice thing. 9-1-1 almost went on strike in my community this year, because of break time the was scheduled and non-scheduled.

    The Medics are an essential service while 9-1-1 Emerg. Officers are not considered an essential service.

  6. I've recently read some news stories about a couple of UK EMS responses being delayed because the crew was on dinner break–a decision I wholly blame the dispatchers for–and often wondered as an American paramedic what the reasons were for this.

    While your experience probably is not the national norm per se, it is definitely eye-opening.

    Thank you, Mark, for the illumination.

  7. I’ve recently read some news stories about a couple of UK EMS responses being delayed because the crew was on dinner break–a decision I wholly blame the dispatchers for–and often wondered as an American paramedic what the reasons were for this.

    While your experience probably is not the national norm per se, it is definitely eye-opening.

    Thank you, Mark, for the illumination.

  8. I've recently read some news stories about a couple of UK EMS responses being delayed because the crew was on dinner break–a decision I wholly blame the dispatchers for–and often wondered as an American paramedic what the reasons were for this.

    While your experience probably is not the national norm per se, it is definitely eye-opening.

    Thank you, Mark, for the illumination.

  9. It's woth noting too that the change to 37.5 hour weeks and unpaid breaks came about for all NHS staff (except doctors who have a seperate system) in hospital and in the community, so paramedics couldn't really complain by themselves.

    The amount of breaks after a certain time working, too are part of the systemwide contract and I think it may be part of European law too, so I'm not sure the government could change it if they wanted.

  10. It’s woth noting too that the change to 37.5 hour weeks and unpaid breaks came about for all NHS staff (except doctors who have a seperate system) in hospital and in the community, so paramedics couldn’t really complain by themselves.

    The amount of breaks after a certain time working, too are part of the systemwide contract and I think it may be part of European law too, so I’m not sure the government could change it if they wanted.

  11. It's woth noting too that the change to 37.5 hour weeks and unpaid breaks came about for all NHS staff (except doctors who have a seperate system) in hospital and in the community, so paramedics couldn't really complain by themselves.

    The amount of breaks after a certain time working, too are part of the systemwide contract and I think it may be part of European law too, so I'm not sure the government could change it if they wanted.

  12. It's woth noting too that the change to 37.5 hour weeks and unpaid breaks came about for all NHS staff (except doctors who have a seperate system) in hospital and in the community, so paramedics couldn't really complain by themselves.

    The amount of breaks after a certain time working, too are part of the systemwide contract and I think it may be part of European law too, so I'm not sure the government could change it if they wanted.

  13. I think the whole break debacle was badly thought out when it came in. Keep in mind that this change was introduced from above, where there were other options available in how to manage working hours. Some ambulance services just paid crews for their breaks and then they were still available during a break. Most others though have adopted the above system. The ensuing disruption and negative headlines were inevitable. The public is worse off because the nearest resource is not sent necessarily and ambulance staff are forced to play this silly game every day trying to negotiate the agreement. It should simply be scrapped , crews paid to be on call during breaks and staff welfare and fatigue managed with stand downs at hospitals or stations.
    Most emergency ambulance staff accept that being on call is part of the job and you join knowing this. Most older ambulance staff were of the opinion that anyone worth their salt would make time for themselves and get fed during the shift. Ambulances should respond to emergencies if they are the nearest resource but staff also deserve rest periods. By scrapping the system, paying staff for their time and the management team taking direct personal responsibility for staff welfare a better system is created and everyone benefits.
    Will it happen? I doubt it but its got to be better than the current way of working.

  14. I think the whole break debacle was badly thought out when it came in. Keep in mind that this change was introduced from above, where there were other options available in how to manage working hours. Some ambulance services just paid crews for their breaks and then they were still available during a break. Most others though have adopted the above system. The ensuing disruption and negative headlines were inevitable. The public is worse off because the nearest resource is not sent necessarily and ambulance staff are forced to play this silly game every day trying to negotiate the agreement. It should simply be scrapped , crews paid to be on call during breaks and staff welfare and fatigue managed with stand downs at hospitals or stations.
    Most emergency ambulance staff accept that being on call is part of the job and you join knowing this. Most older ambulance staff were of the opinion that anyone worth their salt would make time for themselves and get fed during the shift. Ambulances should respond to emergencies if they are the nearest resource but staff also deserve rest periods. By scrapping the system, paying staff for their time and the management team taking direct personal responsibility for staff welfare a better system is created and everyone benefits.
    Will it happen? I doubt it but its got to be better than the current way of working.

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