Firefighters and response to medical incidents

Introduction

It has been fourteen years since the FBU 2001 policy position on co-responder and
first-responder schemes was agreed. Conference 2013 recognised the political,
industrial and public emergency service landscape had changed and continues to
change. The era of austerity is continuing to have a profound effect on all public
services. At the same time the local needs and expectations of community-based
services, particularly in more rural and semi-urban communities, have also been going
through a transformation. Against this changing landscape, Conference agreed in
2013 that the Executive Council should undertake a review of all the additional roles
and responsibilities and all additional work already taken on, or proposed, at local
level and to discuss the issues of new challenges, roles and responsibilities with
employers and with governments.

The previous decisions of the FBU have been justifiably upheld and defended by
members for 14 years. The approach adopted has assisted in protecting the
conditions and standards operating in the fire and rescue service. Some local
employers and some Chief Fire Officers, encouraged and supported by central
government, had sought to:

● Avoid or by-pass national or local negotiations;
● Avoid negotiations or scrutiny over standards and training;
● Enforce such schemes despite such activities being outside the negotiated
and agreed role-maps of FBU members.

By these means they had hoped to create a position whereby changes to roles,
functions and contracts of employment could be forced through without negotiation.
Other organisations have irresponsibly agreed to any scheme, no matter how badly
planned or ill-thought-out. Such actions had the potential to undermine the position
for all firefighters. Fortunately, the resolve of FBU members has largely prevented this
from happening. FBU members should be congratulated since this stance has
thereby protected the bargaining position for all firefighters for future discussions with
our employers on this and other issues.

The discussion within the fire and rescue service about the firefighters’ role in medical
emergencies and related activities is part of that wider discussion about the future role
and function of the service.

Following the decisions of FBU conference in 2013, the Executive Council has
engaged in various discussions on these issues, most notably through the workstreams
created by the NJC, which are the subject of a separate statement to
conference 2015.

There have been various developments in these areas of work since 2001 and there
are no commonly accepted ‘blue light service’ definitions of co-responding and first
responding. The lines are increasingly blurred. There are also other activities which
firefighters undertake (such as moving bariatric patients) that do not fall under these
descriptions. Discussions raised at local and national level have included much wider
issues than the earlier debate about first and co-responding.

FBU conference in 2001 carried an Executive Council statement on first responder
and co-responder schemes. It asked three key questions:

● Are these schemes in the interests of firefighters?
● Are these schemes in the interests of the fire and rescue service?
● Are these schemes in the interests of the public?

In each case, the resolution answered “no”. This policy concluded that: “All FBU
members shall oppose, and shall not participate in any proposed first responder or
co-responder initiative and shall cease their participation in any such existing
scheme.” The policy was endorsed at the 2002 and 2004 conferences.

At the same time the union has been in favour of firefighters receiving good quality
first aid training, some of which has been of a high standard. Since at least 2000,
many fire appliances have carried defibrillators.

During these debates, strong opinions have been expressed from a range of
viewpoints. That is a sign of strength within the FBU. The union has also sought to
keep pace with developments inside and outside the fire and rescue service. The
Executive Council believes the time is right to re-evaluate our policy.
Reviewing our policy

The Executive Council believes the union needs to reassess our policy on medical
emergencies, including co-responding and first responding. This is because the
circumstances in which the union operates have not stood still and are likely to
change significantly in the coming years. Since the turn of the century, there have
been significant changes to firefighters’ work. Since 2000 there has been a fall in the
number of fire and rescue incidents attended. Since 2010 there has been a sharp cut
in central funding to the fire and rescue service, so far of around 30%.

Whilst our opponents commonly claim that the reduction in fires may indicate that
there is spare capacity, it is very dangerous to assume that this allows a reduction in
response resources. The primary role of fire and rescue services is to be ready to
respond to and deal with emergencies. Speed and weight of response is critical to all
emergencies and in fire situations; speed and weight of response will potentially
determine the scale and dangers of the incidents that firefighters will face. The DCLG
review of response times published in 2009 predicted that the 18% increase in
response times between 1996 and 2006 may have caused an additional 78 dwelling
fire and road deaths, and resulted in a £85 million increase in fire damage to other
buildings. Updates to the fire service emergency cover toolkit give a stark warning of
the dangers to increased response times across most emergencies.

DCLG publishes figures for responses to fire and non-fire incidents in Fire Statistics
Monitor: England April 2013 to March 2014. Fire and rescue services attended
170,000 fire incidents in England in 2013-14. There were also 130,600 non-fire
incidents and 223,400 false alarms. Around a fifth of non-fire incidents (27,800) involve
road traffic incidents, while medical incidents along with flooding both account for
around one in ten of non-fire incidents. DCLG does not include the financial cost of
fire that, according to the ABI, is spiralling and the costs of other emergencies, and
indirect costs such as traffic congestion.

These figures do not include the increased amount of work undertaken in relation to
prevention activity and community fire safety. They do not include the need for much
improved safety-critical firefighter training that is absolutely vital to minimise the risks
we face in the operational environment. However the changing pattern of activity is
consistently used by politicians to drive deep funding cuts to the service.
Whilst fire and rescue services in England attended around 300,000 incidents in 2013-
14, the ambulance service responded to 2.9 million category A (immediately life
threatening) incidents. In these circumstances, it is right to review and revisit the key
questions in the 2001 policy and ask whether the answers remain valid.

1) Is co-responding in the interests of the public?
First, the 2001 FBU conference policy asked whether co-responding/first responding is
in the interests of the public? There are a number of important trends that are set to
continue, including an ageing population, an increase in the number of people living
with chronic diseases and rising expectations of patients. According to the Ambulance
Service Network (2008), the number of people aged 65 and over increased by almost a
third (31%) between 1971 and 2006, while there are now over 15 million people living
with long-term medical conditions in England. Thousands of people living in the
communities we serve suffer critical, serious medical events, including stroke, trauma
and coronary heart disease (CHD) – heart attacks and cardiac arrests.

The Arrhythmia Alliance (A-A) charity estimates that 100,000 people die from sudden
cardiac arrest in the UK every year – more lives than breast cancer, lung cancer and
Aids combined. Cardiopulmonary resuscitation (CPR) when used alongside a
defibrillator increases the survival rate from 9% to 50%. For every minute that a
person in cardiac arrest does not receive basic life support their chance of survival
reduces by 20%. The proportion of people who leave hospital and return to a normal
life following a witnessed cardiac arrest in the community is around 15% in places
such as Oslo and Seattle; in the UK it is no more than 5%.

Given these statistics, a public interest case can be made for emergency medical
response by firefighters.

Ambulance calls

The ambulance service across the UK, like the fire and rescue service, is devolved.
There are 10 regional ambulance services in England. According to the Health and
Social Care Information Centre (HSCIC), ambulance calls in England have increased
enormously over the last decade. In 2013-14, there were 9.5m emergency calls to the
ambulance service, compared with some 5.6m calls in 2004-05. In 2013-14, the
ambulance service responded to over 6.3 million incidents, up from 4.5 million in
2004-05. In 2013-14, there were 2.9 million category A (immediately life-threatening)
incidents, compared to 1.3 million such incidents in 2004-05.
Similar trends are found in the other services. The Scottish Ambulance Service
responds to nearly 700,000 emergency incidents every year. The Welsh Ambulance
Service receives a quarter of million emergency calls a year. The Northern Ireland
Ambulance Service receives around 150,000 emergency calls annually, up 17% in last
five years.

Ambulance response times

The 1996 Review of Ambulance Performance Standards set a target for category A
incidents of an emergency response arriving at the scene within eight minutes in 75%
of cases, and a vehicle able to transport the patient in a clinically safe manner, if
required, to attend within 19 minutes in 95% of cases. There was a similar 19-minute
target for category B incidents, but this was abolished by the Department of Health in
April 2011. Although most ambulance trusts meet or are close to meeting the 75%
target, there is significant concern about waiting times of over 60 minutes and with the
postcode lottery in survival rates.

Medical research shows, as would be expected, that survival rates decrease sharply
the longer patients have to wait. A widely-quoted Canadian study found that survival
rates fell from 28% after one minute to 12% after 5 minutes and under 6% after 8
minutes. The fire and rescue service generally has swifter response times than the
ambulance service in urban areas and faster response times is undoubtedly in the
interests of the thousands of people who suffer life-threatening and traumatic
incidents annually.

Effects on the ambulance service

Currently it is estimated that the ambulance service undertakes less than 2% of cases
with the fire and rescue service. So even a five or six-fold increase in the number of
incidents attended will not substantially reduce the number of calls answered by the
ambulance service. Co-responding and first responding are at best a marginal
complement to the ambulance service as a whole – but are considered important
enough to save some lives and to help some people in distress, and to help
professionally-trained paramedics to concentrate on the more medically complex and
serious cases. Critics of FBU policy argue that firefighters could make a small but
significant contribution in this respect particularly given the location of firefighters and
fire stations in some of the remotest of our rural communities.

No one would disagree that when a patient is in need of urgent medical attention that
they should receive the best emergency response care available. In many cases due
to demand or location, there are already many different levels of response. In many
areas, the stark choice is between waiting a very long time for an ambulance or
getting some interim assistance by someone trained to provide an emergency medical
response from within the community. Faced with that choice most people would
welcome the latter. That’s what firefighters could provide.

How many lives could co-responding save? That depends on how widely it would be
introduced, the funding provided, the level of training and equipment/resources
provided and how calls are divided up. It is possible that the rapid response of
professionally trained and equipped firefighters could improve survival rates. Other
lives could be saved through greater specialisation of ambulance staff, attending the
most critical cases knowing that others would be covered by properly trained
firefighters. Andy Newton, from the South East Coast Ambulance NHS Trust, recently
suggested one thousand lives could be saved if co-responding were introduced
universally across the fire and rescue service.

Some say that co-responding would worsen or destroy the ambulance service, and
that we should fight for a properly funded ambulance service. The FBU remains
committed to fighting for properly funded public services, including the NHS. But we
cannot wait or stand aside until decent funding is in place. The FBU cannot stand
back and watch politicians destroy public services through funding cuts – including
our own service - and do nothing. Most co-responding schemes have been in place
for over a decade. From recent experience it is clear that co-responding has not
destroyed the ambulance service. Little wonder given the ambulance service has
attended around 2 million more incidents than they did a decade ago.

What about ambulance workers’ jobs?

Over the last two decades, the number of ambulance calls has grown rapidly. At the
same time the number of qualified ambulance staff (which includes paramedics,
technicians, advanced practitioners and ambulance service managers) has also
grown. HSCIC figures show that there were 18,673 qualified ambulance staff in
England in September 2014. This compares with 17,214 in September 2009 and
14,129 in September 1999.

The number of ambulance workers in England has grown by almost a third during the
period in which co-responding has come into parts of the fire and rescue service. The
Scottish Ambulance Service employs over 4,000 staff, while the Northern Ireland
Ambulance Services employs around 1,100 people. Neither Trust is involved in coresponding.
The Welsh Ambulance Service employs around 2,000 operational staff.
Whatever other problems there may be with co-responding, reductions in the overall
number of ambulance workers jobs is not one of them.
2) Is co-responding in the interests of the fire and rescue service?
Second, the 2001 FBU conference policy asked whether co-responding/first
responding is in the interests of the fire and rescue service? Given the threats from
ongoing cuts and to the democratic governance structure of the fire and rescue
service, there are good reasons for believing it is now in the interests of the fire and
rescue service to include some role in providing emergency medical response in its
portfolio of responsibilities.

During the economic downturn and under the 2010-15 coalition government, the fire
and rescue service has been subjected to unprecedented central funding cuts. Over
the four year period since the 2010 comprehensive spending review, central funding
cuts will have amounted to over 20%.

Central funding cuts announced in the February 2015 local government settlement
earmarked the fire and rescue service for 8.8% central funding cuts in 2015-16. The
Labour leadership has accepted the coalition government’s overall spending limits,
which means that whoever forms the next government, the cuts are planned to
continue. Government statements, corroborated by bodies such as the Institute for
Fiscal Studies, suggest that austerity is planned to continue until at least 2018 and
probably 2020. The FBU will of course fight these cuts. But despite our best efforts,
we have not managed to stop all the cuts forced on the service over the last four
years or earlier.

In these circumstances, the fire and rescue service is coming under enormous
pressure from politicians and other emergency services for closer collaboration,
integration and merger. The current status quo is already shifting and the question is
not whether the fire and rescue service will change, but in what direction. The role of
the FBU in this is pivotal: our attitude to a range of changes under consideration will
be vital in shaping the future direction of the fire and rescue service.

Some fire and rescue services are already responding to medical incidents and in
increasing numbers. DCLG figures, published in Fire Statistics Monitor, show a rising
number of medical incidents attended by firefighters in England and Wales. Over the
last four years, the total number of medical responses has increased from 11,000 in
2009-10 to over 15,000 in 2013-14, an increase of 36%. This is in the context of many
other incidents falling.

Although there are some concerns about the official figures, which lump all medical
responses together, if anything they may underestimate the amount of activity going
on in this area.

In terms of the number of incidents, the recent FBU investigation found that in 2013-
14, the fire and rescue service in England responded to over 24,000 co-responding
and first response incidents. This was higher than the reported figures in Fire Statistics
Monitor.

Greenstreet Berman has recently conducted some future forecasting research for the
FBU. The research suggests that responding to medical incidents (as well as water
rescues) are the most likely growth areas for the fire and rescue service in the years to
come.

At present, the number of medical incidents firefighters respond to is tiny by
comparison to the ambulance service. Demand for medical treatment has risen
consistently for decades and is projected to continue to rise. Therefore there is real
scope for the fire and rescue service to expand its role, without threatening the
continued existence and public need for a professional ambulance service.
Moving in the direction of co-responding represents one of the “least-bad” options for
the fire and rescue service. There is some continuity with existing work and already
some overlap at incidents, whether in the use of defibrillators or the deployment of
HART specialists. It would bring the fire and rescue service closer to its nearest
humanitarian, blue-light partner, with the common goal of saving life and with whom
collaboration already takes place at many incidents. It would enhance the fire and
rescue service’s public reputation as a vital, life-saving emergency service.
Won’t co-responding interfere with the core role of fighting fires?

Concerns have been raised that if firefighters undertake emergency medical response,
then this will compromise fire cover. This is an understandable concern, but has not
proven to be the case in practice, even in fire and rescue services which account for
the majority of co-responses to medical emergency incidents. If emergency medical
response is introduced more widely, such as in more urban and metropolitan areas,
the impact on fire cover would necessarily be a vital issue for consideration and would
have to be kept under constant review.

In general, operational concerns have been dealt with through a Memorandum of
Understanding agreed between the fire and rescue service and the ambulance
service. Although these vary in detail, most stipulate mobilising co-response if various
criteria are satisfied. These criteria attempt to address concerns about fire cover,
categories of calls, distance from the fire station etc. Clearly at present, any such
criteria have not been negotiated by FBU officials. Were the FBU position to alter, FBU
officials would be in a stronger position to negotiate such safeguards in accordance
with FBU policies.

3) Is co-responding in the interests of firefighters?

Finally, the 2001 FBU conference policy asked whether co-responding/first
responding is in the interests of firefighters? There are a number of reasons why
firefighters could benefit from co-responding, and there are now some practical
answers to the legitimate concerns raised in 2001 about firefighters’ conditions.
First, engaging in co-responding to appropriate medical emergencies would
strengthen the argument against cutting firefighter numbers simply because the
number of fire incidents attended has fallen. Of course, the FBU does not accept the
logic of supply and demand, because the frequency of fire and other emergency
rescue incidents does not mean fewer firefighters are needed to tackle and resolve
those emergencies when they do occur. Besides, firefighting is a public good and it is
not appropriate to measure it according to market models. However the union has
faced persistent criticism from politicians to justify keeping public spending on the fire
and rescue service at previous levels, when fires and fire deaths are significantly lower.
Expanding the firefighters’ role to a wider range of activities including response to
appropriate medical emergencies would undercut this argument. This would
especially be the case in many rural areas, although not exclusively.

Second, widening the scope of all firefighters’ roles to include co-responding could
further professionalise the service, as firefighters would rightly expect high-levels of
training and refresher courses to be provided. This should include additional pay for
taking on a wider level of skills and competencies.

Firefighters have never only tackled fires. Since the re-establishment of the service
after the Second World War, firefighters have successively dealt with a wide range of
emergencies, engaged in an ever-more diverse set of special services and carried out
rescues in all manner of civil contingencies. In recent years, firefighters have dealt with
terrorist incidents and with flooding on a wide scale. The challenge for us is if we
restrict our role simply to fires, governments will find other agencies, probably less
qualified, with less solidity, and worse conditions, to do the work. In time, as we have
experienced, they will attempt to develop contingency arrangements to circumvent
firefighters.

Operational concerns

The 2001 policy also indicated a number of significant operational objections to coresponding/
first responding. These included concerns about training and about legal
liability.

The old policy noted that the nationally agreed job description for firefighters expects
firefighters to “apply basic first aid when necessary” and are trained to do so. The new
NJC Firefighter Role Map (2010) concerns a firefighter’s “ability to treat casualties,
using the range of treatment and equipment available to you, within its capabilities
and within your agreed level of authority, responsibility and expertise.” This does not
alter the legal judgement in 2007. Until there is agreement on the specific terms and
conditions of employment, co-responding to medical emergencies remains outside
the contractual obligations of firefighters. However, there is scope for agreement to be
reached at the NJC on the improved training, professional expertise, maintenance of
competencies and associated pay and conditions for firefighters to undertake an
appropriate emergency medical response activities. If firefighters were to undertake a
wider role including dealing with potential medical emergencies it would require
improved training and the support and maintenance of skills and training levels.
The 2001 conference policy stated that “first-responders/co-responders are
vulnerable to, and can be found personally liable for, legal claims. It is because of their
vulnerability to litigation that many ambulance workers take out private insurance
cover”. However in over a decade, there has not been a single case brought against a
firefighter for negligence at a co-responding incident anywhere in the UK where these
schemes have operated.

Recent legal advice from Thompsons indicates that concerns about liability are now
largely without foundation. They have advised that the employing fire and rescue
authority has a legal duty to ensure proper insurance cover is in place. The employer
is vicariously liable for their employees (even if these duties were carried out
negligently) – so the situation is no different from the situation generally for firefighters.
This can also be dealt with in the Memorandum of Understanding between the
ambulance service and the fire and rescue service.

The way forward

The FBU does not accept the approach taken by CFOA towards the ambulance
service. In 2010, CFOA announced that the fire and rescue service should “take over”
the running of the ambulance service, or at least the life-threatening part of it (as
opposed to the transportation side). Experts within the ambulance service quite rightly
dismissed these overtures.

This year CFOA signed a Joint position statement on Blue Light Collaboration with the
Association of Ambulance Chief Executives (AACE) and the Association of Chief
Police Officers (ACPO). The statement supports blue light collaboration and
integration, while recognising the unique skill sets of individual organisations and the
“paramount” need for the ambulance service to remain an integral part of the NHS.

Remarkably, this statement was drawn up without consultation with the workforce –
senior managers appear to believe they can speak for their services without having to
discuss matters with those who actually carry out the work.
Instead of this approach, the Executive Council believes that a thorough and careful
discussion with the fire service employers, seeking appropriate advice as necessary
offers the best way forward.

The Executive Council recommends to conference that:

1. Discussion on emergency medical response continues and is conducted
through the NJC work-streams already established and subsequently at the
full NJC.

2. In these discussions, the Executive Council should seek to address the
various issues of concern raised by earlier policy discussions, including
issues such as operational policies, training, insurance, compensation and
liability, impact on other fire and rescue work, impact on local communities
and other public services.

3. The Executive Council should oversee all such discussions. It is important
that no individual members or committees of the union do anything which
undermines or weakens our position in relation to discussions and
negotiations on these issues. Therefore, any proposed local trials,
Memorandum of Understanding or similar initiatives must be raised through
regional committees with the Executive Council. Any such initiatives involving
FBU members must be formally authorised by the Executive Council before
they are introduced and before any FBU member shall participate.

4. All previous policy in respect of co-responding, first-responding and
emergency medical response is superseded by this policy statement.