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GEO3436 Learning from Experience

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The use of GIS and health care inequality within the out of hours service for Dorset and Somerset.
Healthcare in the United Kingdom is controlled by the government and funded by the public taxes. Wendt (2009) defines this system as a health service provision-orientated type, meaning patients have free unlimited access to doctors. The UK is a member of the International Forum on Common Access to Health care Service, whose members recognise that their citizens should enjoy universal and equitable access to high quality health care (Oliver and Mossialos, 2004). In order for equity to be ensured healthcare services should be monitored (Ben-Shlomo and Chaturvedi, 1995). During summer I worked as an Urgent Care Service (UCS) Bank dispatcher with South Western Ambulance Service Foundation Trust (SWAST). This essay aims to reflect on how the placement has enhanced my geographical knowledge. Firstly I will give a brief description of the organisation and my role, before elaborating on the two geographical ideas. The first is the use of Geographical Information Systems (GIS) in the service which provides the ability for dispatchers to locate, track, route plan and dispatch emergency vehicles (Peters and Hall, 1999). The second aspect is looking at health care inequality and how different areas receive different care. UCS is an out-of-hours GP provider for Dorset and Somerset. Calls initially come in through 111 and are then transferred to the service, if the patient lives in or current location is Dorset or Somerset. The calls are then triaged by an out-of-hours doctor or nurse, who rings the patient back and assesses them over the phone. The clinician decides whether the call can be closed as advice, or if the patient needs to be seen. If a face to face assessment is required the patient can either attend a local treatment centre, or given a home visit. Home visits are either by a Doctor or an ECP (Emergency Care Practitioner) and categorised as either within 2 hours (urgent) or within 6 hours (routine). The dispatchers role is to ensure that calls are dealt with; patients are seen in treatment centres and, most importantly, visited within the allocated timeframe. The two counties are split into areas and one dispatcher covers each area, in the week there are three areas (Somerset, North Dorset and Bournemouth and Poole), whereas at the weekend there are four (with

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Somerset split into East and West.) Overnight there are two dispatchers who cover both counties together. The dispatchers are responsible for managing the doctors, drivers and receptionists in their given area and are the first point of call if they have any queries. 1) Geographical Information Systems within the Urgent care service UCS dispatchers use the same software as ambulance dispatchers, known as C3. The mapping programme allows users to track cars or ambulances throughout the southwest and their current status, whether they are on a 999 call, on a break or free for allocation (with car showing red if busy, black if on a break and green if available.) When users go to allocate a resource the address of the patient is imputed into the map, using satellites and GPS, the software locates the address on the map. Clicking allocate brings up a list of the twenty nearest resources (Figure 1), telling you the distance they are from the patient as well as their estimated time of arrival (ETA). The time and distance information updates as the car moves towards its destination. The ETA is calculated as the shortest route, where GIS analyses the network of roads between the resource and the destination. It takes into account various aspects that influence travel time, such as speed limit and amounts of traffic, finding the shortest path (Dunn and Newton, 1992). This forms an equation, known as the shortest path algorithm, and there are various different methods to create this (Zhan, 1997). This process is not limited to health care, and is used in parcel delivery (Marzolf et al. 2006) and GPS on phones. The system also allows paramedics in ambulances to track nearest hospitals to transport patients to also (Fone et al. 2006). The GPS within the cars allows dispatchers to track cars (figure 2) and see exactly where they are, enabling visualization of route and distances from a car to a patient, providing efficient resource dispatch. Doctors and drivers will occasionally try to avoid going on some visits by asking what other resources are doing, claiming it isnt their area. For example, one night the Bournemouth car was on a visit, when a home visit appeared in Poole. Instead of sending the Poole car out as well, I allocated this visit to the Bournemouth car, there were two main reasons for this; (1) I would had to have closed the Poole treatment centre as there was only one doctor on duty, meaning no more patients could be seen there and (2) the visit was only 5 minutes from where the car already was. Once allocated, the doctor in the car called in to question why she had

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Figure 1 - The allocation screen when dispatching, showing nearest resources along with their distance and ETA.

Figure 2 The map screen allowing tracking of resources, each box is an ambulance, with green signalling available resources and red those on 999 calls.

the visit, to which I explained she was the nearest available resource, she questioned this and

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said it would take her 15 minutes to get there and she would be late for the end of her shift, to which I responded that according to the map in front of me it would take 5 minutes. The doctor then stated that she didnt know exactly how long it would be as she hadnt been given the postcode, in the end she went on the visit but said she will be claiming overtime if she is late back she returned to base 20 minutes before the end of her shift after seeing the patient. Without this GIS information dispatchers would be unaware of cars exact locations, which is evident when signal is lost and causes disruption. GIS is an important and extremely valuable tool for SWAST, it has proven very useful for UCS and even more so for ambulance dispatching, operating in the same way. I have experienced first-hand how It allows staff to effectively and efficiently allocate resources to emergencies in order to minimise waiting time and send a clinician urgently. There are limited studies on the use of GIS within out of hours, perhaps because they wouldnt usually use this as few providers are ambulance services. There are numerous studies on the effectiveness of GIS systems in emergency ambulance responses, varying from Singapore (Ong et al. 2009) to Greece (Derekenaris et al. 2001). The systems have benefited emergency services throughout the world, allowing more patients to be reached within the allowed timeframes (8 minutes for life threatening problems), both in urban and rural areas (Peleg and Pliskin 2004). These systems can also highlight areas where it will be unlikely to meet targets, allowing services to plan a more equal resource allocation of where to station vehicles (Ishfaq and Lodhi, 2012). GIS can also be used to evaluate healthcare access, identifying areas with little access (Hawthorne and Kwan, 2012). 2) Differences between counties Although SWAST covers both counties, healthcare is controlled by separate CCGs (clinical commissioning group) within the NHS whom issue funding. On attending a meeting, I was informed that Somerset CCG are more reluctant to changes than the Dorset equivalent, and so new initiatives are generally implemented in Dorset first, and then the evidence of success is shown to Somerset CCG who would then allocate the funding (or not as the case may be). This does mean that healthcare in Dorset generally advances more quickly than Somerset, and in some areas operates completely differently.

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One of the most obvious differences is the allocation of visits. Initially all visits were sent down to the various cars as soon as they came in, allowing doctors and drivers to plan their route and next visits. This was changed earlier this year to dispatching one visit at a time, giving dispatchers more control of visits and making everyone more aware of the time, ensuring targets are met. Doctors in Somerset resisted this, resulting in it being discontinued, however still operates in Dorset. Whilst some dispatchers dislike the process, I believe it is beneficial to allow dispatchers to plan visits, particularly at weekends. As already mentioned, some staff are reluctant to expand outside their area, questioning work given to them from different places. One of the most common examples is sending a car to a visit which someone else would usually attend, but cannot. I have already mentioned one example of this with reference to the Bournemouth Doctor, but this situation arises throughout the counties at various levels. The Taunton receptionist refused to fax a prescription for a Dorset pharmacy, even though we operate across borders, not independently, whilst nearby in Bridgwater a doctor refused to triage Dorset patients. There are numerous people like this in the service who are disinclined to perform services outside their jurisdiction. This idea of segregation between areas is even more evident overnight. Doctors tend to only call patients from areas they immediately cover (figures 3 and 4), which can prove problematic when cars are out on visits and there is a call for that area. Somerset doctors have also requested two different triage lists, one for each county, instead of the current mixed one. This request was implemented in September, but abandoned due to problems. I believe this could further enhance segregation. Inequality of health care resources can be due to a variety of reasons, such as income inequality, geographical location, and rates of doctors and hospital beds per capita (Horev et al. 2004;). The main reason studied in academia is the reference to income (Andrulis, 1998; Canterero et al. 2004; Judge and Patterson, 2001). Average annual incomes in Dorset and Somerset however do not differ massively, with 24,927 in Dorset and 24,202 in Somerset (South West Observatory, 2012a/b). This, along with the fact that there is no private healthcare in the UK, disregards the idea that income inequality has led to healthcare inequality between the two counties.

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GEO3436 Learning from Experience

University of Exeter Cornwall Campus

GEO3436 Learning from Experience

University of Exeter Cornwall Campus

GEO3436 Learning from Experience

Another idea may be that Somerset being more rural, meaning communities are remote and its harder to access them (Hanlon and Halseth, 2005), but there have been no discrepancies in delivery identified in the study. I think the underlying issue in differences are related to identity. Many of the problems mentioned, where participants are reluctant to extend from their base area can be linked with regionalism. I have struggled to locate academic articles on links between these, so may be a catalyst for potential future studies in the expanding topic of the health care geography (Verhasselt, 1993). As well as these more developed geographical theories and systems, the work has enhanced my general geographical knowledge of local areas. I am now aware of the location major settlements and roads in the counties. This knowledge has been useful when there has been limited cover, as it allowed me to distribute a different resource to an uncovered area, for example when Dorchester had no overnight doctor I moved St. Leonards over. 111 sometimes send calls through to the service for areas we dont cover, meaning we have to know of are as we do cover and alert the supervisor to any out of area calls. Conclusion My placement has provided me with first-hand experience of how vital and effective GIS can be. The benefits it has given SWAST are underestimated, and the organisation would struggle without it. I understand the need for tracking ad route planning, both vital services they offer. The usage of GIS within the NHS has increased considerably in our health authorisations, but there is still potential for this to be extended much further (Smith et al. 2003). National guidance for health authorities will allow it to be used to its key strengths (Higgs et al. 2005). I have also identified and attempted to understand regional discrepancies in delivery, but more academic research is needed. Although no evidence of income inequality exists here, I can estimate how it may influence delivery in private providers abroad.

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Ishfaq, M. and Lodhi, B. (2012) Role of GIS in Social Sector Planning: Can Developing Countries Benefit from the Examples of Primary Health Care (PHC) Planning in Britain?, Journal of Community Health, 37(2): 372-382. Judge, K. and Paterson, I. (2001) Poverty, Income Inequality and Health, Treasury Working Paper Series Marzolf, F., Trepanier, M. and Langevin, A. (2006) Road network monitoring: algorithms and a case study, Computer Operating Resources, 33(12): 3494-3507. Oliver, A. and Mossialis, E. (2004) Equity of access to health care: outlining foundations for action, Journal of Epidemiology and Community Health, 58: 655-658 Ong, M., Ng, F., Overton, J., Yap, S., Andresen, D., Yong, D., Lim, S.H. and Anantharaman (2009) Geographic-Time Distribution of Ambulance Calls in Singapore: Utility of Geographic Information System in Ambulance Deployment (CARE 3), Annals Academy of Medicine, 38(3): 184-191. Peleg, K. and Pliskin, J.S. (2004) A geographic information system simulation model of EMS: reducing ambulance response time, The American Journal of Emergency Medicine, 22(3): 164-170. Peters, J. and Hall, G.B. (1999) Assessment of ambulance response performance using a geographic information system, Social Science and Medicine, 49(11): 1551-1566. South West Observatory (2012a) Dorset (Local Profiles 2012), Website accessed 6th November 2013, <http://www.swo.org.uk/local-profiles/dorset/#.UnrPh_mnfrd> South West Observatory (2012b) Somerset (Local Profiles 2012), Website accessed 6th November 2013, < http://www.swo.org.uk/local-profiles/somerset/#.UnrPjfmnfrd> Verhasselt, Y. (1993) Geography of Health: some trends and perspectives, Social Science and Medicine, 36(2): 119-123. Wendt, C. (2009) Mapping European healthcare systems: a comparative analysis of financing, service provision and access to healthcare, Journal of European Social Policy, 19(5): 432-445. Zhan, B. (1997) Three Fastest Shortest Path Algorithms on Real Road Networks: Data Structures and Procedures, Journal of Geographic Information and Decision Analysis, 1(1): 70-82.

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