Community Innovation… Volunteer Ambulance turns 21!!!!

Twenty One and still going strong! The Houtbay Volunteer Ambulance Service (HBVEMS) is a community based volunteer service working mostly within the indigent communities of Houtbay and immediate surrounds.

Niche volunteer group

What sets the paramedic volunteers apart is the nature of the volunteer. Qualified and registered people who can perform exactly the same work for monetary gain yet choose to perform it for free.  Just to reiterate….HBVEMS performs unpaid, non-compulsory work in their leisure time using some of their own resources within the organizational setting of a volunteer ambulance service that is a registered legal entity.  Some members are full-time paramedics and yet they spend leisure time working for-free shifts.

Volunteer paramedics are exposed to same occupational risks as fulltime paramedics, including but not limited to ambulance crash whilst responding, working in high conflict areas, exposure to Tuberculosis, HIV and other infectious disease.

It takes a fair amount of courage for volunteers that are from non-healthcare environments to expose themselves to the above risks and commit to emergency services. Volunteers who does a 8-5 job followed by a Friday night shift on an ambulance, that live an hour away and happily drive through to work a 12 hour shift, the students that could be partying but are working a shift, there are sacrifices to volunteer!  These volunteers allow the service to exist and they create a strong foundation for future growth.

HBVEMS provides a testing ground into the system and a few volunteers have given up on their previous occupations to become full-time paramedics or pursue careers in health care including nursing and medicine.

In the beginning

The ambulance service was founded by local community members out of a perceived need for expedient emergency care.   Prior to the HBVEMS, the ambulance response time for a priority one case (life threatening emergencies) measured 35 minutes from the Retreat Area where the closest ambulance was stationed.

A group of community members proactively tackled the problem. They searched for ideas and the framework for the organizational structure was adapted from a volunteer student ambulance service, Harpurs Ferry at Binghampton University, New York.  The first volunteers took eight months to complete their basic training and in January 1994 eleven persons qualified as Basic Ambulance Assistants.

Response times prior to HBVEMS

Due to mountains surrounding Houtbay, it is relatively isolated from the rest of Cape Town. Access and egress is restricted; roads are congested with little space to manoeuvre to make way for an ambulance especially when coming over the mountain necks. This impedes on the ability of ambulances outside of Houtbay to respond in time.

The principle indicator of service performance for the Emergency Medical Services (EMS) is response times. This creates a strong case for community volunteer ambulance services in specific areas that can assist over peak times notably for priority calls.  Obviously boundaries need to be set and since 2004 this has been contractually formalised between the HBVEMS and parent body Western Cape EMS and are renegotiated annually.

The typical HBVEMS volunteer

In 2013 the underlying motivation of HBVEMS to volunteer was studied. The Volunteer Functional Inventory was used.  The inventory is based on the theory of functional analysis and has been used in various volunteer settings.  It is based on the hypothesis that although volunteers perform the same functions, they have different underlying motivations to perform the functions.  Two main motives emerged for the HBVEMS: Practising knowledge, skill and abilities that may otherwise not be applied and to express important humanitarian values and concern for others.

The typical member is 29 years old and more likely to be male. Most volunteers are full-time employed and have a degree. The majority does not live in Houtbay.

57% of the HBVEMS also volunteer at other organizations including Volunteer Fire Fighting, NSRI, Life Saving and other volunteer ambulance services. These organizations share a few characteristics:  They all require specialised skill training, a high time commitment, physical fitness, set criteria to volunteer and all carry high personal risk.

The importance of services such as HBVEMS in the South African health sector

According to the Ministry of Health (2012) the South African health care system is on the verge of collapse and in desperate need for innovative action.   The growing demand for health services as result of population growth and the burden of disease are central to this message of impending doom.  The state contributes approximately 40% of all expenditure on health with the public sector delivering services to 80% of the population.

Volunteer Ambulance services can fill a gap and be part of the solution within the EMS system. As mentioned earlier, the principle indicator of performance is response times.  The challenge for operational efficiency is to maximise the fleet over peak periods. The peak periods coincides with times when the volunteers are typically operating.  In 2004 it was estimate that volunteers in the Western Cape made up approximately 30% of any shift in the metropolitan district of Cape Town.  This increases fleet and reduces response times over peak periods.

Response times are prolonged by travel distances, inadequate roads and street markings. Although it may sound trivial, after years of responding within Houtbay’s informal settlements most volunteers don’t need maps and have a good idea of where and how to approach the trickier areas.  Maps and GPS do not show potholes and obstructed routes.

Houtbay and its informal settlements Imizamo Yethu and Hangberg geographically represent a microcosm with its unique socio economic representation of the diversity in South Africa. The informal settlements are a result of urbanization; most residents living in corrugated iron shacks and self-constructed shelters; the majority of HBVEMS calls originate here.  It is estimated that Imizamu Yethu has a population of 20 000 people living within 18 hectares and the 2011 census demonstrated a 51% growth in Houtbay since 2001.

Within the informal settlements there are complex social problems, community conflict is rife and there are high levels of violence. Injuries account for 18.1% of the burden of disease in the province with injury related mortality in men ten times the global average.  (Women: seven times the global average).

Since the inception of the HBVEMS the level of acuity of patients in the Western Cape has risen sharply. This has not been met with an increase in capacity and the demand completely outstrips the capacity.

I sourced some data from the annual report of the Western Cape DOH to demonstrate the capacity and demand mismatch. Note that this is by no means a complete representation of all their performance indicators!

2009 2011 Demand/Capacity
Total population Western Cape 5391765 5634323 Demand
Percentage of Health budget allocated 5% 5% Capacity
Performance indicator  
Rostered Ambulances 230 132 Capacity
Patients transported 404134 446566 Demand
Total ambulance responses 373940 519228 Demand

I excluded the response times for priority calls, an achievement worth mentioning is that the EMS response times for priority calls has dramatically improved possibly due to the implementation of the CAD system.

Capacity concerns

The rostered ambulances are calculated as hours by ambulance personnel worked x hours in a day x two personnel.  It takes into account average number of ambulances available per hour and absenteeism due to sick leave, leave or training.   It is concerning that the number of ambulances has decreased and a contributing factor could be the vacancy rate.  EMS has the highest vacancy rate in the Western Cape DOH.  According to the annual report 32% of the operational posts in EMS are vacant.

It also appears that the funding is insufficient to meet rising demand; this is unlikely to change soon.

The conclusion is that the provincial services have a problem supplying sufficient ambulances per shift to match the demand.

A solution

When operational HBVEMS reduce response times in Houtbay and provides EMS with trained volunteers. This immediately increases the capacity at no cost to EMS.

The volunteers carry their own expenses for annual individual registration, annual public driver permit, indemnity and insurance cover. Most volunteers use their own jump bags containing equipment purchased by the volunteer.

The solution that services such as HBVEMS provide to the bigger health sector is that they provide a basis to develop and recruit future paramedics for the health sector whilst simultaneously increasing the capacity of an overstretched public health sector.

The above is the by-product, HBVEMS exists is to offer patients better care with quicker response times. Having responders within Houtbay allows for faster response times especially during life-threatening emergencies where every minute counts.

Ultimately HBVEMS saves lives.

Congratulations on your 21st HBVEMS, hopefully the first 21 years was only the beginning!

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