Sharp-eyed observers will notice this isn't a Cobra cockpit, but you get the idea.

Also not an actual shot of the action described, but mashing the screenshot button just wasn't a priority. Sorry.

•  A security vessel flying straight through my line of fire as I bore down on a kill, quickly seeing me eviscerated by the irate copper and his colleagues. That's entrapment!
•  A panicked attempt to dock while being scanned with illegal cargo on board (why is it 'stolen' if I found it laying around in space? What about salvage rights?), resulting in me bouncing around inside the docking bay before getting hosed by the sprinkler system of doom.
•  An anti-climactic end to an epic (read: hilariously inept slow-boat circling) engagement between me and another Cobra pilot which was going to the wire until he decided to commit seppuku on my windscreen, sending us both into oblivion.

Put some clothes on love! (Still not a relevant screenshot, aside from the fact that on one disastrous launch attempt this was where I ended up.)

• The Dodgy Hauler (not all spaceships are sexy)
• Hidden Stars (reading the universe)
• The Cobra Money Pit (wall? what wa..)

Rebooted Freebooted?

The Evolution of EVEkind

[This article is a supporting document to the article ‘The Facts Which Informed the Decision to Sack Eddie Daly and an Appeal to Jason Killens’. Names of junior personnel have been redacted at the request of LAS.]

12 June 2014

Dear Mr Daly

Outcome of disciplinary hearing

I write to confirm the outcome of the disciplinary hearing which you attended on Friday 30 May and Tuesday 3 June 2014 at London Ambulance Service Headquarters, Waterloo.

I was advised by [redacted], Senior Human Resources Manager, Ambulance Operations Manager Keith Miller presented the management case, assisted by [redacted], Human Resources Manager. You were represented by Josef Kane.

At the start of the hearing I gave introductions and explained the process for the hearing. I also informed you that one potential outcome of the hearing could be your dismissal from the London Ambulance Service.  This has also been outlined in both the letter inviting you to attend the hearing. I confirmed that all parties had copes of the same documentation and stated that should anyone require an adjournment at any time that this should be requested through me. I then listed the issues to be considered as I saw them that sat outside the allegations being considered at the hearing, these being your grievances; the delays in this process; your wish to have character witnesses present at the hearing; the availability of the Investigating Officer, your crewmate on the day being unavailable to attend the hearing; your view that there had been a lack of support given throughout the process, the lack of transcript and copy of the EOC tape; the priority of sickness absence over suspension.

I took an adjournment to consider all eight issues. As you are aware, I explained my position on these and then dealt with the grievances in more detail. You agreed that the grievances regarding Kevin Brown not chairing the hearing had been dealt with and that bar apologising again for the inclusion of your OHD report in the pack, I could not see what more could be done with regards redress. You agreed with this, stating that it “felt reasonable” and that there was “learning for the LAS” in this going forwards. In regards to the lack of support, we were awaiting contact from your support officer and I said that we would return to this point later in the hearing. With all parties’ agreement, we then proceeded with the hearing.

The purpose of the hearing was to examine the findings of [redacted]’s investigation into the following allegations:

1. You failed to respond to emergency call CAD 707 of 29 May 2013.
2. By your actions you failed to act in the best interests of the patient.
3. You failed to exercise appropriate leadership behaviours as a Team Leader.

You denied all three allegations,  taking a brief adjournment before denying the third. You stated that this was because it was not your “behaviour to  act in that way as a Team Leader or an individual” but because your were “ill at the time”.

Mr Miller presented the management case as per the documents which had been previously circulated. I heard that on 28 May 2013 you were crewed with Paramedic [redacted] on  F102 for an 1830-0630 shift. Mr Miller stated that the failure to respond to an emergency call occurred on 29 May 2013 at 0524 following your request to return to Waterloo to allow [redacted] to return to Westminster for an 0600 hours finish (as no rest break had been allocated during the shift). Whilst the conversations between yourself and the Emergency Operations Centre (EOC) regarding the call were on-going, [redacted] was driving back to Waterloo and away from the call. Mr Miller stated that there was no record of amber to scene being pressed signalling to the control room that you were responding to the emergency call, nor were either of the cancellations accepted when sent. Your vehicle was then made unavailable by EOC at 0540 hours. Mr Miller highlighted Ambulance Service Policy TP/003 Statement of Duties to Patients which states “Staff are required to be ready and willing to work at all times during their contractual hours”. Mr Miller then provided some detail regarding your conversations with EOC.

[redacted], Area Controller, was then called to the hearing as a witness. We heard the tape of your conversations with EOC, including the conversation with [redacted]. During the initial conversations, you were heard to say ” this is not really acceptable”. “sorry mate, I’m not accepting this”, “I think this is unacceptable because I have never had a problem before”, “it is not acceptable and I am not accepting it either”, “I am not accepting it and I think it is dangerous”. During the conversation with [redacted], you were heard to say “you can make us patients too because right now I am tired… I am tired and I am sure my colleague who has been driving all night is tired”, “I think it is dangerous and it is unreasonable”, “it is not fair” (3 times), “it is still not right. I don’t feel this is right”. When [redacted] said “I will say you are not going to take this call and then that is it” you replied with “yeah, thank you”. At the hearing, [redacted] recalled the conversation with you , saying that you had said you were “tired”, but not that you were unwell, nor that you needed to use the facilities on station. [redacted] was clear that in the conversations you had with EOC you could have said “I don’t feel well; I feel sick” but that you did not do so. When asked if you looked different when you spoke to [redacted] on the balcony, [redacted] replied “no” and that you were “just Eddy”. On questioning from Mr Kane, [redacted] said she would “never have thought that you would refuse a call” and that she had “never come across a crew that had refused a call” in her 18 years working in EOC. After some further questioning. [redacted] was released from the hearing as a witness and an adjournment was taken.

On reconvening, Mr Miller continued with the management representations, referring to your investigations interviews and the alleged 31 disparities in the notes cited by you following your interview of 3 July 2013. At this stage, [redacted], HR manager, was called to the hearing as a witness. [redacted] stated that his handwritten notes were contemporaneous notes and that there were no other notes from the meeting. When asked if he considered the notes to be a true account of the meeting, [redacted] replied “yes”. After some further questions, [redacted] was released from the hearing as a witness. As an adjournment was not required, Mr Miller concluded his presentation citing his belief with his supporting rationale that each of the allegations were proven.

You confirmed that your crewmate for the shift had not made a request to return to station nor for you to decline a call.

Mr Kane then commenced the presentation of your case. Due to the time, Mr Kane requested that I hear from the character witnesses first, including their views on a specific scenario (the Bolam test). I agreed to this request and we then heard from your four character witnesses individually. All spoke highly of your character and stated when they thought it would be reasonable to ask to return to station prior to the end of a shift. All four also agreed, albeit one stated if forced, that they would respond to an emergency call which was allocated after they had requested to return. Mr Kane then continued with a number of questions regarding Mr Miller’s presentation. Concerns were raised regarding managers allegedly being aware of the issue, but failing to act. I undertook to take this forward separately and can confirm that I have now done so. Mr Kane also stated that there should have been the opportunity to question certain parties who were not available at the hearing. I questioned how relevant these people were to the central facts as they were not present on 29 May 2013; however I stated that if you had a genuinely held belief that they were central to your case and by not being able to question them it was detrimental to it, I said we would need to adjourn the hearing. I asked that you take a break to consider this.

On reconvening, Mr Kane said that you wished to proceed. As I informed you, I was very clear that the hearing needed to be a fair one and if you felt that it would hinder your case not to question people,  I could not continue the hearing on that day. You said that you wanted to go ahead and that it would not affect your case. On that basis, I agreed that the hearing would continue.

You then presented your case, saying that you had been absent due to sickness earlier that month and had had symptoms for the previous 18 months/2 years. At the start of the shift you said you were “a bit queasy”, but that your pain did not commence until around 0300. You said that you knew you could not have made that call and that you were “desperate to get back”. You said you sounded happy on the original call to EOC as you were looking forward to getting back. You thought the job coming down was “a mistake”. You said you had not reported sick as you were “embarrassed” and spoke at length regarding the Camberwell fire. You said you hadn’t handled things as well as possible and that you were “ashamed” of yourself. You said you felt “let down” by the investigation team and did not know how they had reached their decision. You said you could not have done the call that day “physically or mentally”. You said you would now say you were ill were the situation to arise.

I then asked for the tape to be played again. I informed you that I did not hear you say “I don’t feel right”, but “it don’t feel right”. I then referred to your first interview on 23 June 2013 (which was not challenged at the hearing) where you were asked “did you refuse the call” and you replied “yes”. I put it to you that during the three calls with EOC; the time in between (circa three weeks) and at your interview on 23 June at no point did you say you were not well. Following your suspension, you then stated that illness was the reason for your failure to respond. You said this was because you had “time to reflect”. You then said you had not said you were sick “due to annual leave”. When I repeated this to you, you said this was not the case and that you had been “hiding” your illness. Again you said you regretted “not saying it” and said I should believe what you had said at the hearing.

As there were no further questions, I adjourned the hearing to allow all parties to prepare for summing up.

On reconvening, we heard from Mr Miller, Mr Kane and finally your summing up.

Due to the lateness of the hour, I adjourned the hearing at 2210 hours to consider all that I had heard, having agreed to reconvene on Tuesday 3 June.

On reconvening, I informed you that I would read from a prepared narrative which I attach to this outcome letter for ease.

having found all three allegations proven, I informed you that I did not accept your case that your reason for not accepting the call was that you were too unwell to do so, but that you did not state this. I was of the view that your demeanour on the tape and the number of opportunities you had to state you were unwell did not make this a credible argument. I informed you that I did not believe the proven allegations could be rectified through training, education or a sanction designed to change behaviour as clear and unequivocal refusal of an emergency call is clearly a matter of gross misconduct. “Avoidance of, or non-response to calls, or not acting once a call has been accepted” are all listed in the Disciplinary Policy as issues that fall into potential gross misconduct.

I informed you that my decision was to dismiss you without notice from the London Ambulance Service; your last day being Tuesday 3 June, 2014 the date of the decision hearing.

You are entitled to appeal against this decision. Should you wish to do so, you should write to David Prince, Director of Support Service at London Ambulance Service.

Jason Killens

I maintain this blog because I feel strongly that ambulance clinicians are increasingly being mistreated and taken for granted by the organisations they work for, by the public and ultimately by the government.

The intolerable impact of of this growing disregard is heartbreaking to witness as we ever more frequently read about patients who have been needlessly failed by struggling services and of dedicated staff who have had their ability to continue flogged out of them. The former circumstance is frequently the fodder of the mainstream media, but the latter rarely finds it way past sterile data on staff attrition and sickness.

Banging the drum for hard-working and undervalued ambulance folk has been a fairly solitary occupation and often it seems as I’m only ever preaching to the choir (a readership for whom I am very grateful). Many times I have wondered if the public even care, or if they remain oblivious and apathetic until the bubbles of their healthy existences are popped by unexpected illness or injury (at which point many who felt the service was inadequate would just point the finger of blame at the attending clinicians or their Trust).

After attending the End Austerity Now march in London on Saturday (20 June 2015), I feel buoyed by the evidence that clearly not all are so removed from the harsh realities suffered by a health service under siege (and indeed I know from experience that not all service users are unsympathetic to the challenges road staff face). An unconfirmed estimated 250,000* people marched from the Bank of England to Parliament Square to express their ire and frustration at government policies which are negatively impacting the lives of millions. And I am grateful for that.

*more conservative estimates state closer to 80,000

The march was so law-abiding, we even stayed on the correct side of the road (mostly)

Having never attended such an event before, I had some trepidation. Demonstrations rarely make the headlines unless there’s trouble, and that was something I did not want to be part of. But I did want to be part of a movement which is pushing for positive change which could provide some relief to my fellow clinicians. I wanted to know that folk existed who were thinking about people beyond their own closeted existences. I needed my faith in humanity restored after our nation was plunged into a 5-year orgy of selfishness and greed by the general election results.

I felt it important to attend because the core principle of the campaign was to end austerity, a government-inflicted stranglehold on society which lies at the heart of the reason why ambulance services are struggling. The ongoing NHS ‘efficiency savings’ demanded by the austerity drive impact pre-hospital emergency services both directly and indirectly. As well as ambulance trust funding continually failing to meet rising demand year after year, leaving an inadequate amount of clinicians to deal with an impossible workload, healthcare cuts elsewhere inevitably filter back into the demand for ambulance services as local A&Es are closed, GP services buckle, patients are discharged too early to resolve bed shortages.

Sadly, this was the closest I ever got the the National Health Action Party group.

So I headed into London and kept my fingers crossed that I wasn’t heading into an angry mass of violence and kettling, but something more life-affirming.

I was glad that I took the chance. What I experienced was like a carnival, a mobile Glastonbury festival, but with added politics. It was more a celebration than a confrontation. The overwhelming majority of people were just ordinary folk that you’d see in a supermarket or down the street. There were families, children, senior citizens, working-age adults of all varieties. It’s fair to say that there were also some colourful characters, and some intimidating ones, but even menacing thugs have rights. Thankfully, I witnessed no trouble and the BBC report I saw subsequently suggested there was nothing more than a small bonfire of placards and a gang of potential troublemakers who had the temerity to move some barriers a bit. The police were stern but approachable and I was grateful for their presence. I stopped and thanked a few. After all, we were marching for them too.

The march itself was punctuated at the beginning and the end by public addresses from numerous figures; activists, politicians and celebrities. Although the hovering helicopters often made it hard to hear every speech clearly, I caught much of what was said by the likes of Natalie Bennett (Green Party leader), Dr Jacky Davis (consultant radiologist, NHAP and Keep Our NHS Public member, co-author of NHS For Sale), Len McCluskey (general secretary of trade union Unite), Martin McGuinness (Deputy First Minister of Northern Ireland), Jeremy Corbyn (Labour Party leadership candidate, whose rousing speech was very well-received) as well as celebrities like Shappi Korsandi, Francesca Martinez, Mark Steel (sharp and sarcastic), Charlotte Church (whose words were compelling) and Russell Brand (who was, well, Russell Brand – perhaps with a dash of extra deference, offering himself as a servant to the cause ‘in whatever manner you see fit’).

Dr Jacky Davies addresses (some of) the crowd before they set off.

Overall it was an immensely positive experience and full credit should be afforded to the organisers, The People’s Assembly. The rally has given me a sliver of hope that at least some people have a conscience and a sense of social responsibility to stand up for ambulance staff, other public sector professionals and the vulnerable people they serve.

Even though none of the quarter-of-a-million attendees hold the reigns of power, they all are constituents of those who do. Members of Parliament on both sides of the green benches must surely take note of such a loud call for social compassion and decency when it comes time for them to vote for or against a policy. If nothing else, I can at least take some solace in the fact that there were hundreds of thousands who do feel things are going wrong and need to be righted, even if their particular agendas varied from mine. There were blocs of marchers for womens’ rights, students, immigrants, racial tolerance, the disabled, public sector workers, animal rights activists, even caravan owners(!) and many more, all united by the understanding that austerity is cruel and unnecessary and that we should find a better, more positive way to improve our society.

Various signs were handed out by attending groups.

At least I hope so, because the one quote that stuck in my mind was from one of the activist speakers whose name I didn’t catch. With suggestions of general strikes already finding their way onto placards and into many trade union speeches, I found the message to David Cameron from the unknown speaker of ‘If you make our lives unbearable, we will make this society ungovernable’ quite chilling. That’s not what anyone wants, any more than austerity. But I can also see that other options are becoming increasingly thin on the ground.

I can only hope that this march woke up some compassion both across the land and in the halls of power. This is still a democracy right? Not a 5-year dictatorship. Surely the population can still influence those who serve them in government?

Otherwise, either under the oppressive yoke of Tory policy or because of increasingly militant opposition, things are going to get worse for everyone.

Parliament Square full of people less than pleased with the usual residents of the nearby buildings.

This video by WellRedFilms gives a great overview of the event, showing the diversity and the sentiments of the participants. Well worth your time (even though the figures quotes regarding incoming cuts are vastly understated – the £12bn mentioned is for welfare alone, a further £22bn is hitting the NHS).

My thoughts on and reasons for attending the protest against the current government ideology can be read in my previous post, but as I spent much of my time taking snaps of the assembled masses (until my battery died), I thought I’d share some here.

As I exited Bank tube station, it was immediately clear I was in the right place.

The Socialist Party were clearly well-prepared to get their message out.

I wasn’t quite expecting the carnival atmosphere. Or a giant balloon hand. I idly wondered if the NUT operators planned to attempt a few gestures at the Houses of Parliament.

Judging by their level of preparedness, the Fire Brigades Union must have done this sort of thing before. I bet they’ve got a hammock in there.

That’s unfortunate. I really need to learn to take more than one shot.

As people gathered, the streets filled with colour and noise…

… well, some streets. In my historical re-enactment days I learned the hard way not to mess with charging horses. Evidently most people didn’t need such a painful lesson.

The Essex Feminist Collective and Southend’s UNISON representing.

Co-ordination and inspiration came in the form of a series of speeches from organisers and key individuals like Green Party leader Natalie Bennett and activist Dr Jacky Davies.

As I explored the growing throng, I was slightly concerned to see a group who felt the need to hide their identities, but they were a tiny minority.

A mobile rock band with their drummer on a rickshaw entertained the crowds.

Quite possibly the march’s youngest protester?

One of the more colourful banners. I suspect a Blue Peter badge was involved.

The butterfly supporting immigration made me smile. There was something poetic about it being nestled among the more militant signage.

As I ducked down a side street, a squad of police with riot gear rushed the other way. I hoped nothing untoward was occurring.

My detour to get to the head of the march before it started made me stumble across this sinister lot. I moved on quickly.

… the police were aware of the group and were quietly monitoring their activity.

In stark contrast, just around the corner at St. Paul’s Cathedral, the Salvation Army played a dainty tune as some kind of St John Ambulance presentation took place.

I got to the head of the protest as it set out and the diversity of the protesters soon became clear as they marched toward me up Ludgate Hill.

Bankers masturbate while Vesus saves. Or something.

I was disappointed by the lack of close harmony singing from the Welsh contingent.

Caravans Against Austerity? Um, okay.

The Norfolk contingent. This lady was giving me a smile and a friendly wave, not trying to hide from the camera as it appears.

Apathy Schmapathy!

I admire his candour, but I’m not sure that’s a sound economic policy.

Go on little fella!

Still not singing, but at least they brought their dragons.

What the hell ARE you doing, Dave?

No, I don’t know what ‘unanquishable’ means either. I think they missed out a ‘V’. Maybe it’s a subtle reference to V for Vendetta.

‘Over 200 dead women in 18 months [due to] domestic violence.’

Here comes the scene-stealing FBU battle bus, with ‘unity in strength’ emblazoned on the side.

Rumour has it that David Dickenson was so enraged by government policy that he spontaneously combusted half-way along the route.

This street performer treated us to a very funny satirical number about Ian Duncan Smith’s welfare policies.

Approaching Parliament Square, the positive vibe continues (and passing tourists look bemused).

As we pass the war memorial in Whitehall, it strikes me that it is a shame that it is necessary for the police to take these measures to protect a monument to those who fought and died for our right to peaceful demonstration.

Approaching Parliament Square, we are greeted with a big screen for those who can’t get close enough to see the stage.

I chuckled. Her boyfriend can shower, but I think a more ‘industrial solution’ would be necessary for the other problem.

The first few thousand already in place, eagerly awaiting for the speakers to appear on the stage.

As the likes of Jeremy Corbyn, Len McCluskey, Charlotte Church and Russell Brand spoke earnestly about the state of society and what could be done, people continued to flood in. Half way through the speeches it was announced that the final protesters had just departed the starting point.

In a country of beleaguered ambulance Trusts facing staffing shortages, pay freezes and dwindling resources, things are looking bleak right now for employees and the public alike.

But there is a glimmer of hope.

After a desperate few years, East of England Ambulance Service has been experiencing the beginnings of a positive shift in culture and attitude. A change which, if successful, could show the way for other Trusts and prove to be the template for the much needed shot in the arm ambulance services nationwide need. Among other things, this grassroots initiative led to the production of the powerful and incisive video below about pressure and late finishes and accompanying petition, which solicited this encouraging response from the Association of Ambulance Chief Executives. But it’s an initiative that needs your support, wherever you are in the country.

Although this blog’s recent focus has been on London Ambulance Service’s institutionalised abuse of its workforce – a conclusion borne out by the recently published, damning independent investigation into bullying and harassment – LAS’s current culture echoes that of EEAS’ in the past. With the recently announced departure of LAS Director of Operations, Jason Killens, it seems every bit as plausible that London staff could hope for a positive shift in their fortunes in the future. It just takes the right kind of bold and positive influence and leadership.

The kind which Dr Anthony Marsh is providing for EEAS in his role as Chief Executive.

During his tenure, Dr Marsh has proven to have an ear for staff and public concern, supporting moves to address late finishes, stopping the practise of fudging response time figures through the use of single-manned rapid response vehicles where a double-staffed ambulance is more appropriate. He has encouraged increased transparency and communication. He has backed a push to support wage increases for low paid Trust staff. He has started to build a belief that the workforce is valued. In his Clinical Governance Report of 2013. he challenged the kind of negative culture which brought EEAS to its knees in the past and has more recently seen LAS fall from grace. But there is much more which still needs to be addressed – his work is far from done.

Sadly, the remaining proponents of EEAS’ former, negative culture are understandably not happy with the threat Anthony Marsh poses to the status quo and are making moves to oust him, already preparing his replacement in the wings. Dr Marsh’s departure would be a regressive move for the Trust and the public it serves. It would endanger any hope of continued positive change and threatens to see a return to the blinkered and damaging practises of old.

If ambulance Trusts around the country are to find a way to evolve past the archaic ‘command & control’ management structure which has proven to grind staff into the ground, if they are to mature into a public service which supports its staff and delivers the world class service the country expects, then we need to stand with progressive leaders like Dr Anthony Marsh, who is also chair of the Association of Ambulance Chief Executives.

It is for these reasons that East of England staff have been running a petition to the Secretary of State for Health asking for support to keep Dr Marsh in their Ambulance Trust. Hundreds of staff have signed the petition, which says, ‘We believe that without Dr Marsh things will again quickly start to unravel in our Ambulance Trust; there are already discussions to remove some of the supportive changes we have seen, and this is severely impacting morale. We feel we need to petition you [Jeremy Hunt], as we do not believe our Board is acting in our best interests.’

Frontline staff are traveling to Parliament on 20th July (next Monday) with the support of former Minister of State for Care and Support Norman Lamb and other MPs. I will be travelling with the group and hope that they will be listened to and supported by MPs and the Secretary of State for Health. I’ll post details of our mission both on this blog and in other social media.

They, and I, would be most grateful for your support and help. This could be a tipping point for ambulance culture nationwide.

Please follow this link to sign the petition.

Chloe Smith (Con), Norman Lamb (Lib Dem) and Daniel Zeichner (Lab) accept the petition from Fraer Stevenson

Earlier this week, a group of East of England ambulance staff travelled to Westminster to deliver a petition appealing for better working conditions for road staff and to retain the services of the chief executive who supports them. Their hopes were to gain ministerial support to help persuade the Secretary of State for Health to intervene and allow them to retain Anthony Marsh longer term as their Chief Executive.

I was fortunate enough to be able to travel with them to get a better understanding of the issues.

As I sat on the minibus heading for Parliament, I listened to the conversations of the ambulance staff who had taken time out from their home lives to maintain the push for positive change within East of England Ambulance Service (EEAS). The group exchanged stories about their front line experiences and the organisation that facilitates them with all of the disgruntled passion I recall from the crew rooms of old. It was this kind of cathartic debrief which allowed under pressure ambulance personnel to offload and vent. I knew how valuable these conversations were, despite often seeming critical or negative, as a way for ambulance clinicians to feel their concerns were being heard, even if only by each other. It was how they coped with the burden of their work.

Sadly, these days the growing pressure for ambulance Trusts to perform with ever dwindling resources leaves road crews with little opportunity for such informal confessionals as they are rarely on station to meet each other. Back to back emergency calls, aggressively enforced hospital turnarounds and soul-sapping late finishes mean that individual crews are often ships passing in the night.

But hopefully today their concerns would be heard by a far more influential audience.

Given their discussions, I was a little worried that their message might get lost under a deluge of anecdotes about inappropriate emergency calls and internal politics. Fortunately, as we arrived in central London, the spokeswoman of their merry band said a few words to ensure that everyone was clear on the matters in hand. Fraer Stevenson, ambulance clinician and UNISON Branch Secretary, underlined the importance of focusing on the key issues of the petition they carried; supporting moves to offer staff greater protection from late finishes and backing incumbent Chief Executive Dr Anthony Marsh to stay in post despite pressure from the board for him to be replaced.

On first impression, Fraer cut an unusual figure as the individual at the epicentre of the struggle for staff welfare. A diminutive blonde woman with a small voice who, while having the bedside manner of Florence Nightingale, you might think would be out of her depth dealing with headstrong and determined executives. Apparently not; a steely determination to fight for what is right, whatever the cost, hides just beneath the surface.

I had only spoken with Fraer once before today, a lengthy phone conversation (after weeks of missed calls) had revealed she and I had been walking a parallel path for a long time. Concerns about East of England Ambulance had prompted me to start this blog back in 2012 after I became aware of a growing outcry among North Norfolk residents at the poor service they were getting from EEAS. Fraer was involved in much of what I went on to write about on The Broken Paramedic during that period: campaigning when staff grievances were ignored and seeking support from concerned Norfolk politicians including Norman Lamb (Lib Dem) to the battle for EEAS’s soul against a misguided executive board which eventually stepped down. The catalyst for much of that was a brave and candid stand made by staff at Cromer Ambulance station on the North Norfolk coast. I believe that the corner which EEAS is perceived to have turned is very much something for which Cromer staff deserve no small amount of credit.

Is Anthony Marsh the Right Man for the Job?

Dr. Anthony Marsh, EEAS & WMAS Chief Executive

After piecing together our shared history, I took the opportunity to air some niggling concerns I had about the purpose of her mission to Parliament. Nationally, ambulance staff are in a desperate situation and I’m unequivocally behind anything that will give crews a better chance of surviving their own careers, but why is she so convinced Anthony Marsh is worth fighting for? Since publishing my previous article backing the petition to retain his services, I’d been contacted by various parties who expressed concerns about the move, from decisions he made at West Midlands Ambulance Service to his failure to address a bullying culture allegedly present within East of England. It seemed that not everyone was as convinced as she was that he was the right man for the job.

Her reasons were manifold. Now she is UNISON branch secretary, she has a good ‘partnership’ relationship with Anthony Marsh, enabling her to push for positive changes which benefit staff, pushing for improvements to the diabolical conditions they labour under and ultimately bolstering their ability to provide a good service to the public. She believes that Mr Marsh is a good man making brave decisions to right a listing ship. She identified some of the supportive measures he’d brought into EEAS include upskilling paramedic and EMTs to band 6 and 5 respectively, saving about 100 staff from having to leave the Trust after the loss of Patient Transfer contracts (under TUPE [Transfer of Undertakings (Protection of Employment) Regulations 2006] legislation they would have been absorbed by private providers) by bringing in a new tier of health care referral teams undertaking urgent work.

It is fair to say the role of any ambulance trust chief executive (or indeed any other senior management position) is a poison chalice. In the current target-obsessed, resource-starved climate, it is an impossible mission for anyone, but Fraer presented plenty of evidence to suggest that Mr Marsh is at least willing to factor staff needs into his strategies. The same may not be said of any replacement waiting in the wings, especially given that, due to the current period of uncertainty, many positive proposals under Anthony Marsh have already stalled and current changes threatened with reversal. Any incoming chief executive will surely be expected by the board to continue down that line.

Whatever your thoughts on Anthony Marsh’s tenure, the ground made in EEAS under his watch is at stake and I’m inclined to give him the benefit of the doubt, largely because Fraer is. I am convinced she is absolutely a force for good, someone who is prepared to stand up for staff and stand up to the less savoury aspects of ambulance culture, even to her own detriment.

Parliamentary Friends

Clive Lewis (Lab) and Gavin Shuker (Lab) listen to staff concerns.

When we arrived in Westminster, the meeting itself went well, with some encouraging dialogue taking place between the assembled ambulance personnel and the MPs who found time to escape the halls of power on the day of the Welfare Bill debate.

Gathering on the green often used by the reporting media outside Parliament, we were met by Chloe Smith (Conservative MP for Norwich North), Daniel Zeichner (Labour MP for Cambridge), Norman Lamb (Liberal Democrat MP for North Norfolk), and later by Clive Lewis (Labour MP for Norwich South) and Gavin Shuker (Labour MP for Luton South) all of whom were attentive and supportive, listening to concerns and supporting the petition. It was fantastic to see such positive cross-party support.

Norman Lamb talking to BBC Look East

I was particularly impressed with Norman Lamb, who I’ve always viewed as sort of a kindly uncle, but in person was far more steely. His commanding performance in front of the BBC Look East camera showed that he was a very capable man able to marshal facts from conversations he’d had moments before into what sounded like a polished, pre-prepared speech. His comments were insightful and had weight, asking ‘is it wise to lose a chief executive who has the confidence of staff and has made real progress.’ Certainly, it’s worth considering that, in light of concerns about Anthony Marsh’s other role as West Midlands Ambulance Service chief, he has still had successes, where his full-time predecessors had failed.

Thankfully, all of the MPs pledged to do what they could for the cause, with promises to write to Jeremy Hunt, Secretary of State for Health, to bring the matter to his attention. I hope it’s a matter which Mr Hunt feels is worthy of his time. After all, now more than ever, he is a man who could do with the opportunity to appear supportive toward the needs of NHS staff.

Perhaps more importantly, I hope that the East of England executive board are able to see whatever influences are driving the decision to oust Anthony Marsh and to make the right choice to support the staff that make their organisation work.

NHS 111 services sit in the eye of a nationwide healthcare storm.

Amidst a chaotic vortex of hospitals in special measures, funding and resource concerns, escalating demand, demoralised healthcare staff and belligerent health ministers, the public continues to need treatment – and it is to the 24/7 medical helpline to which they often turn.

As a paramedic who has recently taken up a position as a clinical advisor in Hertfordshire’s 111 service (run by Herts Urgent Care), it has given me an opportunity to see first hand the efforts to mitigate the unprecedented pressure on wider NHS services.

Sadly, the impression given by recent press coverage paints a bleak picture of those efforts (Daily Mail: ‘NHS 111 Whistleblower Speaks Out‘, Independent: ‘Most people told to go to hospital after calling NHS 111 did not need emergency treatment‘). I’d like to take this opportunity to offer an alternative, more informed viewpoint than the kind of fearmongering anecdotes which have been the focus of much mainstream media coverage.

I am all too aware of the intolerable workload faced by my colleagues delivering 999 emergency care and the related challenges faced by A&E departments. GP services are also in crisis as are other community-based services. So it is absolutely imperative that whatever can be done to alleviate the pressure of relentless demand on primary care services (that being the umbrella term for any ‘first point of contact’ to healthcare, including GP surgeries, A&E departments and ambulance services, amongst others) whilst maintaining the standard of patient care people expect from the NHS. This is no small task and is fraught with risk.

It is vital to recognise that 111 does not exist to replace any of those services. It cannot. It is a supporting service which should enable its users to get the right care in the right timeframe. However, primary care is a minefield for the uninitiated. To expect the layman to know the urgency of their need and which point of access would get them the care they require is a huge assumption.

Risk Aversity Versus Safe Practice

Sourced from the internet – unkind and incorrect

Much has been made of the scripted process of assessment, provided by NHS Pathways, and its use by the non-clinical health advisors who take the majority of initial 111 calls. While the health advisors do not generally have an extensive clinical grounding, I have found them to be knowledgeable and passionate about the service they are providing. It is evident that the experience of dealing with the healthcare-seeking public dozens of times in a single shift soon gives them insight and understanding of the vast majority of the calls they field.  Of course, as non-clinicians, they are required to stay strictly within the constraints of the Pathways assessment, with any complex or concerning issues being transferred through to a clinical advisor.

The point of the Pathways assessment itself is to attempt to leave no stone unturned when ruling out medical problems which are not appropriate to be dealt with over the phone. It’s a robust system which formalises the process which any clinician would be instinctively doing the moment they laid eyes on their patient. Using the system, there is no reason why an experienced non-clinical health advisor cannot provide as safe and thorough an assessment over the phone as a clinician. For the most part, the limitations lay not with their ability or training, but with the obvious restrictions of being on the other end of the phone, unable to physically assess the patient.

In an ideal world, every member of public would know the difference between a sleeping patient and an unconscious one, or a minor wound and a potentially catastrophic one. But that is simply not the case, so before any attempt can be made to address the problem at hand, those risks need to be identified and ruled out.

It’s fair to say that, prior to my training, I had my reservations about the idea of being able to make any kind of reliable assessment of an unwell patient without actually being in the same room as them. But my experience over the last few months has given me plenty of reason to be assured that the process works for the most part.

Room For Improvement

Having undertaken the health advisor training as a precursor to my clinical induction, I spent a number of shifts working in that role. I did experience a degree of frustration as I was required to switch my paramedic brain off, relying purely on Pathways to identify areas of clinical concern. Despite that, as I worked through the assessment with my caller, I would be mentally noting what information I would have sought and almost without fail, the Pathways assessment would cover it (and often far more besides). Indeed, as I progressed on to my clinical advisor role, I found that, with transferred calls requiring further clinical consideration, the brief handovers health advisors provided would often show they had a good grasp of the underlying clinical concerns, even if they couldn’t qualify them.

That’s not to say the system works perfectly every time. Of course it has its limitations and there is most certainly room for improvement (something which I hope to discuss in subsequent articles), but in my experience, the sheer volume of calls which are dealt with and result in a positive outcome unequivocally prove that NHS 111 provides a useful service and does much to protect the public and the interconnected primary care services.

There is of course pressure not to send ambulances inappropriately, just as there is clear guidance on the use of other primary care services, and this is something which any regular reader of this blog will know I feel strongly about. It is guidance which is entirely appropriate. The idea – as suggested in some media coverage – that patients are being wilfully denied ambulances when they need them is ridiculous and would be unethical.

I have dealt with a few cases where I know the ambulance crew despatched would probably be cursing me, and if I could call them to justify my decision, I would. But the limitations of telephone triage make it impossible as a clinician to take the risk based on the information provided by the caller.

But the number calls I’ve dealt with which have ended with the caller happy to deal with their problem at home who might otherwise have called an ambulance or taken themselves to A&E comprise the vast majority of my workload. Those kinds of calls vastly outweigh the occasional ones in which the need for immediate care cannot be completely ruled out I have no doubt that NHS 111 is a net positive both for professional healthcare services and for the general public.

The Real Problem is Lack of Education and Resources

Broadly speaking, I suspect any perceived pressure coming from NHS 111 arises from ever increasing public demand,  not inappropriate referrals. NHS 111 provides a wide and accessible safety net which may well be accurately highlighting that increase in demand. In its absence, I have little doubt that the increase in pressure on other services would be far greater.

I wish we had more ambulances so the occasional over-cautious referral didn’t punish crews so much. I wish so many A&Es hadn’t been closed and GP services weren’t in such dire straits that I feel a twang of guilt every time I choose to err on the side of caution by sending the individual for assessment when my gut suggests it might not be necessary.

But I certainly don’t see the concept of NHS 111 as an appropriate target for attack by various media outlets and even some healthcare professionals. Without it, things would be far worse.

In any case, I’m glad there are employment alternatives for staff who have been fed through the front-line meatgrinder and  I won’t be compromising on my goal of endeavouring to provide the best and most appropriate care for every individual I deal with.

While the healthcare storm continues to rage around us and the NHS suffers the ongoing assault of the government’s misguided efficiency savings programme, I am grateful, despite the adverse conditions, to be able to provide clinical guidance and for the opportunity to work alongside health advisors and fellow clinicians who work hard to do the same.

The primary care sector and public should be grateful too – things would be worse without 111.

[Disclaimer: The views and opinions in this article are solely those of the author and are not representative of Herts Urgent Care or its partners.]

Dear frontline ambulance colleagues,

After 12 years of responding to 999 calls and subsequently watching from the sidelines as family and friends continue to do so, I am only too aware of the ever increasing pressures and the ongoing erosion of the ambulance clinicians’ lot. Poor staff support from within ambulance organisations and the lack of comprehension from government (most recently exemplified by Jeremy Hunt’s ‘ambulance driver’ comment) continues to frustrate me as I’m sure it does you.

I’m grateful for the opportunity the Broken Paramedic web presence gives me, allowing me to keep in touch with the mindset of many of my fellow clinicians on various issues that bubble up in the mainstream media. Thank you for contributing. For the most part, this level of interaction helps me to consider perspectives I might otherwise not have considered, which in turn informs many of the conversations I have with journalists who occasionally contact me for advice and PR-free clarification (not that this relationship moderated the misguided vitriol of certain Mail Online journalists, but lesson learned).

However, when it comes to certain issues, I can’t help but notice that there’s a degree of misinformation and prejudice which colours some of your responses.

For example, a comment received in regard to my recent employment as a 111 clinical advisor was as follows:

“…Unfortunately, the reality is that you and your colleagues will routinely pass calls to the ambulance service that are nowhere near that serious and you all know it. I think it’s fair to say that 111 is despised by many of those in the ambulance service. You’re so risk adverse, it’s pathetic… Personally I don’t know how some of you sleep well at nights having passed the absolute dross you do to us.”

Ouch.

In defence of this unnecessarily personal attack, from my own frontline experience I recall how angry I would get when yet another fatigue-inducing shift seemed to have been made all the worse by needless, time-wasting call-outs. I would frequently demonise what was then NHS Direct and also my own service’s dispatch staff. Today, it’s the medical advice line, NHS 111, which is perceived by many to be a root cause of unbridled ambulance service demand. Discontent under pressure breeds interdepartmental animosity, it seems.

As I’ve mentioned previously, last year I took up a post as clinical advisor at Hertfordshire’s 111 service, a decision I took both out of professional curiosity and financial necessity. I can report the last six months has been a largely positive experience; I once again have the opportunity to directly help those in need and to make more constructive use of my knowledge and experience. Furthermore, it has given me a fantastic vantage point to see the difficulties facing healthcare provision – and they are manifold.

As such, I would like to take the opportunity to address some of your concerns and criticisms in the hope that you consider my viewpoint that NHS 111 is not quite the misguided, incompetent debacle some would like to paint it as. To this end, I have put together a few key facts and ‘mythbusters’ that might help the likes of Anonymous Angry Commenter above.

One caveat is that my experiences are exclusively based on my time at Herts Urgent Care in Hertfordshire and it should be noted that not all 111 providers have the same resources or working practices. Indeed, Herts Urgent Care tends to perform better than most in the national figures and I do not currently have access to the information to explain any disparity. Further, I don’t have the number-crunching resources of the Office for National Statistics and all figures cited have been pruned from sources linked at the foot of this article.

1. The NHS Pathways assessment software is risk averse and sends ambulances needlessly.

The software is risk averse, but not needlessly so. Here’s why:

While the vast majority of 111 calls are from individuals with minor ailments or other non-urgent needs, on occasion 111 callers are not always aware of – or prepared to accept – that they may be dealing with a life-threatening condition. As a result, it is not uncommon that people call 111 when they should be dialling 999 or attending an emergency treatment centre. Ideally, every member of public would be able to identify the onset of a stroke, heart attack, severe breathing problem or other potentially major problem, but ambulance staff of all people will know that is simply not the case. As such, Pathways is designed to rule out the presence of any ‘red flag’ symptoms as quickly as possible so the caller can move on to a more symptom-specific assessment.

It’s fair to say that over the phone, this is a potential minefield. The inability to see the patient means that the call-taker is reliant on the information given by the caller. There are a multitude of reasons why this is sub-optimal, and that is the key limitation of telephone triage. While there is of course room for improvement, there is no way to make such a system fool-proof. No call-taker, clinical or not, is going to be able to guarantee they can be 100% accurate in separating indigestion from infarction, stroke from Bell’s palsy, or hypoxia from hyperventilation. Not without a physical examination to rule things out.

So sometimes an ambulance gets sent when – even though its recognised that the worst case scenario is unlikely – it would be unprofessional, unethical and dangerous to do otherwise. We cannot not diagnose over the phone, even if every call was dealt with by a clinician.

2. Call handlers are prompted to ask ridiculous and irrelevant questions.

Some of the questions call handlers are prompted to ask during the assessment process can seem inappropriate or unrelated to the presenting problem, such as asking the caller who has been speaking freely during the initial conversation if they are fighting desperately for every breath, or having to ask the mother of a feverish baby if the child has been to a West African country affected by the Ebola outbreak in the last 4 weeks.

However, even though in the vast majority of cases the answer would seem to be an obvious no, imagine the outcry in the rare cases where those factors were in play but no attempt to identify them was made. For the record, both the above-mentioned breathing question and a further question regarding skin temperature are intended to catch signs of sepsis.

3. Calls to 111 are initially dealt with by non-clinical staff.

Mostly true. 111 Health Advisors, a.k.a. call handlers, are largely non-clinical (although there is the occasional clinician in training). They undergo 2 weeks of classroom work which gives them a grounding in identifying more common life-threatening signs and symptoms, but are strictly required to stay within the framework of questions as set out by the Pathways algorithm. Further training is ongoing during their employment and their growing experience should not be discounted either.

Furthermore, the call centre is always staffed by a mix of health advisors and clinical advisors (nurses, paramedics, midwives and other allied healthcare professionals). They work closely together and any call which Pathways wants to send an ambulance response can be checked with a clinician. Once past the initial [module 0] questions – and even during these questions in some cases – any potential ambulance response is verified by a clinician. In many of these cases, the clinician will advise the health advisor to transfer the call to a clinical advisor for ‘further probing’. Health advisors cannot deviate from the Pathways outcome (known as a ‘disposition’), but clinical advisors can override this, and frequently do when an appropriate alternative is available.

Clinical staff do help out with calls when demand is high and on the one occasion I’ve taken a call from a paramedic who assumed I was a health advisor, I found him to be quite condescending and rude. He was so abrupt, he didn’t give me an opportunity to explain my role or qualifications. Nonetheless, after he terminated the call I did my best to address his request for an immediate GP callback at the scene of a peri-arrest patient with a DNAR. Sadly he went on to make his decision without the GP’s (or my) clinical input and I fear he might have made a different choice had he taken the time to engage with me rather than bark down the phone.

Respect costs nothing, even in difficult circumstances, whether you’re talking to a health advisor or a clinician.

4. NHS 111 would be more effective if all calls were handled from the outset by clinicians.

There are a number of reasons why this would not necessarily be the case. Notwithstanding the challenges of telephone triage as mentioned in Point 1, the sheer scale of this proposal in the face of the current demand makes the idea impractical.

Last year (2015), nationwide 111 dealt with nearly 1.1 million calls every month. The majority of those calls are for minor ailments, non-urgent problems or other enquiries (‘I can’t get through to my doctor for an appointment’, ‘my child has a runny nose’, ‘can I take paracetamol and ibuprofen?’, ‘I need a repeat prescription’ etc.). It would be a monumental waste of tax payers’ money to have qualified healthcare professionals deal with these issues. It makes as much sense as insisting GPs man their own receptions.

Even if it was financially justifiable, the current challenges within the NHS means we hardly have an excess of healthcare professionals to make an all-clinician telephone triage service viable.

To put this line of thought into context by comparing the current climate with that of 111’s predecessor NHS Direct, which did favour clinicians as an initial point-of-contact, here’s some stats to compare.

• In 2006/7, NHS Direct’s busiest day (23rd December) saw 25,000 calls. An average day in 2015 saw 35,000 calls dealt with by NHS 111.
• In 2006/7, NHS Direct answered 68% of all calls received within 60 seconds. In 2015, NHS 111 achieved 91.4%.
• In 2006/7, NHS Direct referred 32% of all cases to ’emergency and urgent’ services. In 2015, NHS 111’s figure was 19% (11% ambulance, 8% emergency treatment centre).

5. Ambulances are sent even if the caller has refused one.

Within the Pathways process, this is not true. Any ‘disposition’ [the recommended course of action arrived at by the assessment process] offered by a health advisor can be refused by the caller, at which point the call will be passed over to a clinical advisor.

At this point, the judgement of the clinician takes precedence over the Pathways disposition. Of course no ambulance is going to be sent without good cause and if there is an appropriate alternative treatment pathway, that would be explored – and in many cases it enables us to work with the caller to arrive at an informed and safe decision. However, in certain circumstances, healthcare professionals have a duty of care and may be required to act in the patient’s best interests in spite of their preference. We would only do so if there was no other option, and would ensure that ambulance dispatch was informed of the situation.

These circumstances are relatively rare, but with increasing challenges faced by community mental health, patients discharged prematurely without appropriate home support, and other underfunded and buckling systems, it’s a sad truth that the ambulance service is the only option in certain circumstances, lest the system abandons these people entirely.

6. Abandoning NHS 111 altogether and leaving the public to decide on the most appropriate treatment pathway would relieve pressure on 999 and other services.

This is hard to prove without actually doing it, but it seems very unlikely. With GP services facing a national crisis, A&Es already overburdened and ambulance service utility spiraling out of control, I would imagine a significant proportion of people who currently rely on 111 and out-of-hours GP services would simply call 999 or attend A&E out of desperation.

I believe some ambulance personnel are suffering from confirmation bias. Every ambulance attendance generated by 111 which turns out not to be as it initially appeared is held up as an example of failure, whereas the thousands of calls which might otherwise have resulted in a 999 call are never seen by ambulance staff.

As stated before, telephone triage is limited, sometimes there is no option but to have a clinician on scene to rule out things which may (or may not) require immediate attention. I’m genuinely sorry that this often means engaging ambulance clinicians who might otherwise be attending more obviously life-threatening situations, but that is a problem created by a lack of ambulance service resources and a growing population of elderly, infirm and vulnerable people, exacerbated by a broader failure of government to provide appropriate support and prevention measures.

Millions of people rely on the service provided by NHS 111 and for most, it is effective and useful. It is something of a Pandora’s First Aid Box. Now the system exists and the box has been opened, it is nigh on impossible to put everything back, even if we wanted to. I believe to remove the facility altogether would increase pressure on other services, not protect them. It would be better for ambulance and 111 services to work together to improve the relationship between them.

In conclusion

I accept that NHS 111 is an imperfect system and that it does contribute to the pressure which impacts of the daily experiences of 999 crews. But I hope you will see that there are valid reasons for the calls generated. If there were enough ambulances to shoulder the demand, it wouldn’t be an issue.

For what it’s worth, I certainly hope to participate in making the process more effective, but even if there was a way to guarantee every ambulance referral was appropriate to the skillset of an emergency ambulance crew (which there really isn’t), I suspect it would make little difference to the intolerably high utilisation rates under which crews toil.

The truth is that the general public will always seek the quickest route to solving their problem and healthcare organisations will always try to provide this on the lowest possible budget. There is a lack of high-level foresight in the utilisation of ambulance crews; the powers that be seem to work on the principle that replacing is more acceptable than protecting when it comes to the workforce. The beancounters think an ambulance crew not dealing with an attendance is one that is wasting money. This is compounded by the current ideologically-led efficiency savings suffered by ambulance services and by the competitive market model which 111 providers have to adhere to, creating all sorts of limitations (underbidding leading to cost-cutting measures, private provider need for profit, unwillingness to work openly with potential competitors).

The accessibility and convenience of NHS 111 and 999 services means that initial contact with primary healthcare has never been easier. Along with a growing and aging population, I believe this is the cause of the rise in demand. Like ambulance services, NHS 111 cannot deny the public treatment if there is any possibility that it may be appropriate. Making that determination is the key factor here – what  an individual wants and what they need are not necessarily the same thing. And making that decision over the phone is even trickier than doing it on scene.

Ultimately, 111 and 999 are on the same side and should find ways of working more closely together to deliver the right care to the people who need it. There’s little to be gained from animosity.

Of course, if even after taking all this into account, you feel you need to continue scapegoating 111, then I can’t stop you. I’ve been there – sometimes you just need someone or something to kick. But at least you’ll hopefully now be doing it from a more informed position.

Sources:
Gov.uk: Connecting Health and Home: NHS Direct Annual Report 2006/07
NHS England: Ambulance Quality Indicators Data 2015-16
NHS England: NHS 111 Minimum Data Set 2015-16

Last week, I was invited to speak at the NHS Pathways National Partnership Forum, a gathering of 111 providers, clinical commissioning group representatives, technicians and policy-makers who are focused on improving the telephone assessment service. I took the opportunity to offer some insight into the ‘view from the trenches’ in support of encouraging an evolution of the system toward a more positive and effective working relationship between 111 providers and ambulance services.

This is the transcript of my presentation (along with some of the slides).

Good morning, my name is Mathew and I work as paramedic clinical advisor at Herts Urgent Care – 111 providers for Hertfordshire, Cambridgeshire and Peterborough. 

The reason I’ve been invited to speak today is because earlier this year I made some impact in the mainstream media in an attempt to address some widely perceived misconceptions about the 111 service. It is my hope that I might also be able to provide you with some insight into the complex relationship between Pathways-trained clinicians and our frontline brethren.

So I’d like to take this opportunity to share with you some of my thoughts and experiences relating to that, from my perspective as a 111 operative, a former frontline ambulance clinician and in particular as an active user of social media.

You see, I’m in a fairly unique position as a result of a few unexpected twists and turns in my paramedic career. If you’ll indulge me, I’d like to give you a little background.

After more than a decade as an emergency ambulance clinician, I retired from frontline service in 2012 due to a spinal problem which – at the time – left me with some mobility problems and quite significant pain. As I recovered slowly at home, the time gave me the opportunity to start a blog, the Broken Paramedic, which enabled me to address and discuss concerns and issues that affected the ambulance sector.

Well, I say I ‘took the opportunity’, in truth, it was my Mother who convinced me to redirect my blogging experience to challenge growing fears about ambulance cover in her locality of North Norfolk, which had already been suffering from a poor level of service and was facing a further reduction in ambulance cover. Ultimately, common sense prevailed and the level of ambulance cover was actually increased.

I was surprised by the impact of my first few blogposts and I soon found myself being invited to write an ‘expert opinion’ column in the Daily Mail’s campaign against A&E closures. 

Since then, the Broken Paramedic online presence has grown organically into something of a loose community comprising allied healthcare professionals and interested members of public, which continues to cast a critical eye on many aspects of the ambulance sector – and associated primary care interests, often quite ferociously. Contributors certainly don’t always agree.

I’ve been able to challenge some of the more dogmatic aspects of ambulance culture, and to give a voice to those who might previously have been silent. For me, one question keeps popping up: who cares for the carers? 

It has also given me the opportunity to work with various other media outlets and documentary teams, including a number of radio appearances and even a brief visit to the red sofa of the BBC Breakfast studio.

It was in August last year that, for various reasons, I applied for the role of 111 clinical advisor in my home county of Hertfordshire.

I think it’s safe for me to say now that – as well as being curious – I was, like many of my frontline colleagues, a little suspicious. My time out on the road at East of England Ambulance Service had left me with a disdain for anything that I perceived to be causing unnecessary pressure on increasingly beleaguered ambulance staff. In my time, this was an accusation often leveled at NHS Direct, our own dispatch, the ambulance management, the Trust board, the government, the public. Sometimes it was justified. Sometimes it wasn’t. But in any case, it was no surprise to me that contemporary staff were pointing the finger at 111. 

The experience of working in emergency pre-hospital care shapes you. In many ways this is a good thing, helping to develop clinical knowledge and the soft skills that working in such a varied and challenging environment requires. But in other ways it causes damage. For most normal humans, it’s just not possible to sustain a consistent levels of empathy, clarity and tolerance for 13, 14, 15 hours of consecutive emergency calls.

So I approached my new role with some trepidation, acutely aware of the fact that I was signing up to be the primary scapegoat for my former colleagues and my readership.

As I grappled with the concepts of telephone triage and using the Pathways tool to support my clinical assessment I started to see the similarities between and the differences from my former frontline role. 

The differences were obvious; I now do a lot more sitting down (which is great for a dodgy back), and I encounter far fewer traumatic sights and strange smells (notwithstanding the occasional peculiar lunch choice from the next cubicle). I’ve not once had to find a change of clothing halfway through a shift. The hours are a lot more predictable too.

But there are similarities. The emotional reward of spending some time helping somebody who is struggling to cope in some way is something I had missed during my retirement. But now as a clinical advisor I get this dopamine hit far more frequently than when I was on the road – my rate of positive interactions can now be upwards of 5 an hour rather than a few times a shift.

The oddest similarity, and perhaps given the focus of this forum, most relevantly, is that Pathways is essentially my new crewmate.

Ask any ambulance roadstaff and they’ll tell you that your crewmate is of critical importance to your working life. How you work together to get the job done defines what the patient, your crewmate and your own self takes away from the experience. There are ideal crewmates and there are those that are… less than ideal. I’ve had both. I’ve been both.

It’s that buddy-buddy relationship that has been the focus of so many Hollywood movies and I think the chapters of every ambulance clinician’s career are defined by the crewmate they had. Of course, I went on to marry one of my crewmates, so perhaps I’m biased.

In any case, Pathways has big shoes to fill. (I’m not saying that my wife’s got big feet or anything, you know what I mean).

This is the professional relationship that empowers your clinical decisions, that keeps you on track when your focus drifts, that comes up with that genius insight that hadn’t occurred to you. This is what Pathways is excellent at.

Of course it’s also the working relationship that provides moral support when things aren’t going well, takes over if you and the patient aren’t quite connecting, and knows how you like your coffee. Pathways is absolutely terrible at that. 

Over the last year, my relationship with Pathways has evolved, and it’s been an education. It’s often been the reliable, no nonsense Sherlock to my empathic but meandering Watson. It’s grown from a slightly jarring, forced interaction into a productive, effective relationship, despite Pathways’ tendency to railroad the conversation and interject with ridiculous requests (‘no Pathways, I’m pretty sure this elderly, bed-bound dementia patient hasn’t been to West Africa in the last month’).

I soon came to realise the importance of the work we do at 111 and the impact it has on primary care, particularly the emergency ambulance sector. I realised that some of my more frustrated frontline counterparts were getting things wrong.

They’re not wrong to be frustrated with their lot – I know how it feels to be stretched thin, used and abused and squeezed to the point of broken exhaustion on a regular basis. They’re not wrong to identify when a 111-generated emergency ambulance response turns out to have been inappropriate to the patient’s needs. They’re certainly not wrong to identify that there is room for improvement – of course, there is.

But I believe the are missing the mark to lay the blame on 111 staff or the service as a concept. My experience of a functioning 111 call centre has been diametrically opposed to the horror stories the likes of the Daily Mail has portrayed in recent months. Day in and day out I see good people working hard to provide an informative, empathetic and professional service which the demand clearly shows that the public wants and needs.

Which is why I felt it was important to leverage the social media platform I had built to challenge the misinformation peddled by some mainstream media outlets and to address the concerns of my ambulance brethren.

With Herts Urgent Care’s endorsement, I was able to use my media contacts to provide an alternative view in The Metro, which was well received and widely read to the point that I was approached by ITV News to provide a counterpoint to their prime-time story on concerns being raised about the safety of the 111 service. It is my belief that much of the concern arises from a broad misunderstanding of the service provided and the limitations, both among the general public and, it turns out, some healthcare professionals.

Following on from that used my Broken Paramedic blog to tackle some myths and misconceptions that persist among ambulance staff.

This was generally met with a conciliatory tones of understanding and agreement from my ambulance readership, although some concerns raised are valid and worthy of further consideration – particularly with regard to the information which is or isn’t passed from Pathways to ambulance dispatch to attending crew. And of course there are always a few who are just too angry to hold a conversation with. 

But I didn’t come here just to say how great I think 111 is – there are some uncomfortable truths that need to be faced by 111 providers, ambulance trusts and the general public. Absolute safety cannot be guaranteed nor should it be promised. Healthcare just doesn’t work that way.

But I don’t think we should be shy about showing how safe and effective 111 currently is, nor should we back away from discussing how it can be improved.

The growing call demand that 111 and 999 services are experiencing is evidence of the public’s faith in both. However we need to foster greater faith in each other.

Some of my most rewarding work is when I successfully identify cases Pathways wanted to send an ambulance to which can be safely downgraded. Some of the most frustrating moments are when I have no choice but to send an ambulance on safety grounds, knowing that in all likelihood the attending crew will be silently cursing my name for wasting their time and unnecessarily adding to their exhaustion.

It would be of great benefit for both of these kinds of cases to be part of a better communication between 111 providers and ambulance services, but not at the committee level – at the grassroots level. If my clinical assessment could land on the screens of the attending ambulance crew to explain the reason for their attendance, I think a lot of hearts and minds could be won. Equally, if the attending crew had a better way of sharing their findings with clinical advisors, then all parties would learn and feel part of the same team – which we absolutely are.

Ultimately, I signed up as a 111 clinical advisor, not only because I wanted to return to helping the vulnerable and the infirm, but because I wanted to do something to help my ambulance brothers and sisters. I genuinely believe that as well as being an advice service for the general public and the gatekeepers of primary care service, we are the guardians of the well-being of our frontline colleagues.

After all, who is in a better position to care for the carers if not us?

Derrick was about to die.

Shrouded in the empty blackness of a vast, subterranean cavern, Derrick Stoneballs – second-storey man and lifelong criminal – clung to the vertical rock face and gave his predicament careful consideration even as his muscles screamed for respite.

As a dwarf, he accepted his people’s cultural fondness for rocky terrain, but he had decided there was a special place in The Abyss for this particular precipice upon which he was stranded. In whichever direction he chose to clamber, the cliff had an unknown and probably miserable fate prepared for him.

Out in the darkness to his right he could still hear the faint sounds of violent subjugation echoing from the chasm-top prison he’d recently escaped. Suspended from huge stalactites which thrust down into the darkness, the drow slavers’ structure was cunningly hidden above shadows cast by craggy outcrops and the webs of terrifying giant spiders.

Some indeterminate distance below Derrick was the icy water of an underground river fed by a nearby tumbling cascade, whose persistent susurration provided another layer of obfuscation for the clandestine drow structure. Brief consideration of taking his chances by dropping into the flow had been quickly dismissed as Derrick’s fellow escapee, a derro named Buppido, had done the same only to be heard falling victim to something that dwelt in that dark water.

Generations of subterranean life had gifted Derrick’s kind with functional vision in the underdark, and his senses told him that his rock face escape route came to an abrupt end not much farther to his left.

The only unknown direction was up, and his fatigued limbs and the unforgiving cragscape would only make exploration in that direction all the more treacherous. With fatalistic realisation, Derrick had begun to accept that his grim end seemed an imminent certainty.

Unless, he mused with blackest mirth, he suddenly sprouted wings or the ability to teleport. With delicious irony, the imagery brought back untimely recollections of perhaps when this terminal run of luck had first begun…

‘Writing is its own reward,’ is a misquote of the little-known actor who played Feyd-Rautha in David Lynch’s 1984 sci-fi epic, Dune. He may also be known for other deeds, mostly tantric sex and naming himself after Bilbo Baggins’ sword. Its unclear if those last two activities are related.

The laboured and meandering point I’m trying to make with the above paragraph is my explanation for the creation and purpose of this blog. I enjoy the process of writing, from refining an idea into a structured form to sharing the end product and seeing how others respond.

As detailed in the about section at the top of this blog, I’ve got previous form on blogging about various topics, but in recent years I’d stopped. I left my various blogging endeavours scattered around the interwebs, gathering virtual dust.

Speaking to friends and family about the concept of unifying my previous blogging efforts under one new banner, the consensus was that it was a silly idea. Maybe it is, but I’m doing it anyway.

Reviewing my writing trends over the years has made me realise that – although the focus of my writing may change – the desire to write never does. Is it really necessary to start a whole new blog every time a fresh topic beckons?

Besides, I still keep a weathered eye on previously covered topics close to my heart and it’d be nice to have the opportunity to revisit some of them. I’m still tinkering around under the bonnet with all these fancy new WordPress blogging widgets and it will probably take some time to get things working optimally. Please bear with me as I attune my brain to this new world of themes, formats and categories.

Content planned may well focus more immediately on my rediscovered love for roleplaying games, but computer games, films and TV, personal and public healthcare issues will certainly feature at some point, and maybe – if I’m brave enough – politics too.

Onward to new writing, a broader remit and an older head.

See you soon.

Over a quarter of a century ago, I was a Dungeon Master.

Then life happened; career, mortgage, marriage, kids. The funny-shaped dice gathered dust.

Yet over the passing decades, the impact of those teenage roleplaying game sessions has resonated through my life. Not least the fact that I’ve remained close with the school-friends who shared my nascent RPG journey, but also perhaps influencing my tastes and decisions as an adult. For example, I became a paramedic and got married in a forest to a woman with elven cheekbones.

In many respects, my friends and I stayed faithful to our gaming roots by embracing the internet age and playing a multitude of online variants of the games that drew us together. However, despite the astounding evolution of technology, no massively multiplayer or co-op gaming experience has ever quite captured the magic of our fantastical teenage odysseys (which is what led me, during my brief flirt with games journalism a few years ago, to write the bitter lament ‘Massively Multiplayer Online Role Playing Games are a Lie‘).

From time to time, my friends and I would still get together in the real world for some tabletop gaming action (Games Workshop’s Warmaster mostly), but too infrequently to make our pen-and-paper habit worth resurrecting. Our life choices had seen us spread across the UK and beyond, making continuity a challenge.

In hindsight, it remains a mystery to me why we had never before attempted to use modern technology to bridge the gap between old and new. At least until last year, when it was suggested we give it a try using Roll20‘s browser-based RPG toolset.

The luddite in me resisted, unconvinced that the pen-and-paper RPG magic could be recaptured through the keyhole experience of computer monitors. I find comfort in the creative chaos of being surrounded by rulebooks, sheets of paper and scattered dice, as well as being able to make proper eye contact with fellow players. I saw online connectivity as detached and sterile.

But we gave it a go and, although I was slow to embrace this new-fangled interwebby roleplaying paradigm, have to admit I am now fully reborn as a 21st century Dungeon Master and digital roleplayer. As well as running two concurrent Dungeons & Dragons campaigns, I’m a player in Warhammer Fantasy Roleplay and Star Wars: Edge of the Empire campaigns run by my friends, all on Roll20.

My long dormant love affair with D&D now rekindled, I realise I’ve got a vast amount of catching up to do – there’s been like a thousand (well, three or four) new editions of the rules and a ridiculous amount of source material which I’m just never going to be able to absorb.

Not only that, the days of getting an occasional fix from a monthly magazine are long gone, now there are countless blogs to discover (Sly Flourish and The Monsters Know What They’re Doing are already favourites), forum communities, podcasts, YouTube/Twitch channels, direct social media engagement with roleplaying luminaries, online resources like D&D Beyond (which is either everything my heart desires or heresy depending on the wind direction).

It’s a bit overwhelming and a far cry from the insular RPG experience of the 1980s, but coming to terms with my D&D culture shock, overcoming the prejudices of my youth, and making old mistakes with new tools seems like a good topic for some bloggery.

Watch this (wild)space.

Returning to Dungeons & Dragons after a quarter-century absence was always going to be a challenge. But I may have underestimated just how much.

Mistakes were made.

Pick a World, Any World

I have vague recollections of being a reasonably competent dungeon master once, but they were simpler times. As a group of teenagers in the pre-internet age, roleplaying games were a much more isolated, almost clandestine pursuit.

Delivering an engaging roleplaying experience to that same group, now forty-somethings with far broader knowledge and world experience, more particular tastes, and less time to waste was an intimidating prospect.

The first potential hurdle was choosing a campaign setting that suited everyone. In an effort to start our new D&D campaign off on the right foot, I chatted to my once-and-future-players to get a measure of their expectations. There wasn’t much appetite for a return to our old haunt of Krynn and the Dragonlance saga, or any similar D&D universe with what they now perceived as tired old high fantasy clichés. Bloody sophisticated grown-ups!

To be fair, I was fine with moving away from familiar material as I was keen to explore some more abstract metaphysical storylines and had been considering blowing the dust off my old 2nd edition Planescape and Spelljammer sourcebooks.

However, I was wary of biting off more than I could chew. There was already a lot to absorb. Not only was much of the 5th edition entirely different to the 2nd edition we vaguely remembered, our life-paths had spread us far from our home town, across south-east England and beyond, meaning we would be relying on Roll20 and Skype to hold it all together.

Finding an out-of-the-box campaign seemed to be the solution while we found our feet, and Out of the Abyss looked just the ticket. Although technically set in the Forgotten Realms (a campaign setting for which I held an unjustifiable disdain for due to some bizarre teenage KrynnForLife tribalism), the themes of demonic incursions, (demi-)human trafficking and slavery set in the endless underdark seemed to cater perfectly for my aging audience’s darker, more cynical palette.

Dicing with the Internet

We enthusiastically created characters for our four players and I ran a couple of solo/duo mini-sessions just to give us all a chance to grapple the basics like: how does combat work now? What’s a proficiency bonus? Where did Hide in Shadows go? And what happened to THAC0?

Early hurdles overcome, I looked forward to the opening session of the campaign proper, whose introductory chapter Imprisoned by the Drow seemed like a perfect ‘bottle episode’ to slowly allow the narrative to unfold and the player-characters (and DM) to acclimatise.

I carefully prepared the colourful cast of non-player-characters who begin incarcerated alongside our PCs, making notes including voice cues or facial expressions to help distinguish each. Embarrassingly, I even rehearsed a bit, which drew some odd looks from my wife, who was just discovering these previously dormant new depths of eccentricity.

Despite an initial suspicion of the internet-based roleplaying paradigm, I embraced all the sound and lighting wizardry provided by Roll20, carefully crafting a persistent map environment which would account for light sources and character’s darkvision (or lack thereof) as well as preparing a number of atmospheric ambient soundtracks.

Debut game night came around and D&D began in earnest. It felt good, the self-consciousness and stage fright soon dissipated, and things seemed to flow fairly naturally as the PCs took stock of their surroundings, interrogated NPCs and plotted their escape from Velkenvelve.

But a promising start to an otherwise reasonable campaign launch was marred by a number of key DMing errors.

Dungeon Not Mastered

Things seemed to be going well, in the first session the players got their combat fix from a couple of prisoner-on-prisoner scuffles which gave me the opportunity to emphasise the numerical superiority and power of their drow captors and their quaggoth and giant spider servants. I naively thought that this would surely make the players recognise that fighting their way out would not be a viable escape option – especially given that the party comprised a dwarf rogue, a half-orc barbarian (with stealth skills), a goliath druid who could turn into a rat, and a gnome monk. They all had stealth, survival and athletics/acrobatics – this group were the perfect infiltration/exfiltration squad. They were bound to come up with an ingenious and stealthy plan.

Er, no.

Come the second session, after making me sweat by testing my (weak) engineering knowledge with demands to know the precise technical specifications of the metal cell door, including the hinge mechanism, lock design and anchor points (none of which were included in the source material), the PCs decided to mount a full-on Spartacus-like uprising, coercing all their fellow prisoner NPCs to get involved.

This presented me with a binary choice: let the event play out as it had been designed, which was almost certainly going to result in a bunch of overconfident low level PCs taking a beating or worse, or contrive some way to make their escape attempt work for them. I felt the second option would have undermined the integrity of the campaign, as making everything seem too easy would just make the players think they were invulnerable. This had been one of the concerns raised in our pre-campaign discussions about high fantasy, so I went with the first option, dooming them to failure.

Unsurprisingly, the escape attempt barely got past the open cell door. The gnome monk and the orc barbarian were eviscerated by an elite drow guard and the goliath druid was thrown to giant spiders waiting in the chasm below. The dwarf rogue was the only successful escapee and the session ended with him clinging to the chasm wall unsure of his next move (and there he remains, leading to this piece of flash fiction).

Two NPCs died too, an aggressive orc named Ront who had already made an enemy of the PCs, and a more amiable gnome gambler called Jimjar. Fortunately, the presence of drow priestesses meant I could fudge PCs deaths and have them back in their cell, courtesy of Lolth the Spider Goddess. But all in all it was a messy and unsatisfying outcome.

This already strained event was made all the worse by my decision to re-roll individual initiatives every combat turn with the intention of creating a more dynamic combat. This may still prove to be worthwhile for more intimate one-on-one melees, but it was sheer folly to attempt it in my first big combat encounter, especially with upwards of a dozen individual combatants.

Breaking Down the Breakdown

Ultimately, this experience – along with other factors unrelated to roleplaying – dampened enthusiasm (largely my own) and led to a break of several months before we collectively returned to Velkenvelve for a second escape attempt.

This time, in order to move the story on, I lowered the difficulty a shade by using the scripted demon attack featured in the source material to make the majority of guards (and particularly the more challenging drow priestesses) go missing while one scheming drow officer (Jorlan Duskryn) arranged the release of the prisoners to further his own agenda.

My haphazard DMing did lead to one accidentally delicious unscripted moment. As the party searched for an exit to their chasm-top prison, they stumbled upon a wounded elite drow warrior in his stalactite chamber. On opening up the NPC token details on the Roll20 interface, I discovered it to be Jorlan himself. He was losing the brief confrontation which ensued and, after he spat in the half-orc’s face, his interrogation became an execution as the PCs took out their frustrations on him, ending whatever powerplay the scar-faced drow may have been engineering. His failure and death seemed a symbolically fitting end to the first chapter.

I went on to make further – and arguably more egregious – DMing errors,  but I’ll admit to those in another post. Suffice to say that we got through it and the campaign is on a far better footing now.

I’d welcome any feedback, advice or similar experiences in the comments below or on Twitter (@Freebooted).

Thanks for reading.

How many Players Handbooks does it take to change a lightbulb? To be honest, I couldn’t tell you; I’ve got three 5th edition PHB versions and no lightbulbs have yet changed. Let me explain…

Over the last year or so, my newly awakened Dungeons & Dragons passion has slowly eased into digital age. It’s been a joy discovering the many fantastic tools and websites that are now available to players and dungeon masters alike. The sheer volume of material available is gloriously overwhelming.

But hidden among this glory is a degree of frustration. I’ve now paid for the 5th edition Player’s Handbook three times! And this vexes me.

The hardback book came first, out of habit. You can’t beat a solid, weighty tome for that sense of ownership and value. A generous player later donated/loaned me a number of other 5th edition books (MM, SCAG, VGtM, MToF), which was more than enough to get our campaign underway.

Then came the D&D Beyond digital version of the Player’s Handbook, which I found to be a far more convenient way to access the information to support online play. The interface is slick, nicely presented and very smartphone friendly.

Unfortunately, I couldn’t get my players to embrace using it, largely because character creation felt restrictive unless you’d spent a fortune on rebuying all of the character creation content scattered across several tomes.

Additionally, as we were already using Roll20 for our online sessions, my players didn’t much care for having to switch between the two platforms for information.

So my D&D Beyond investment was reduced to a DM’s reference tool. Over the following months, I purchased the Dungeon Master’s Guide and some official campaign material which, in conjunction with the Forgotten Realms wiki, has become the mainstay of my game session preparation. I felt it was a shame the D&D Beyond service didn’t have a virtual tabletop component like Roll20, or at least some kind of cross-compatibility, but I was content to do the cross-platform admin as part of my game prep.

Enter the Charactermancer

However, Roll20‘s recent upgrade to include a character creation tool, the Charactermancer, suddenly awakened me to the prospect of Roll20 evolving into the catch-all solution I’d hoped for. A short tinker with it made me realise that, like D&D Beyond, it was frustratingly restrictive without the content, so I took a punt and bought Roll20’s edition of the 5th edition Player’s Handbook.

I was pleased to discover it works really well, taking a logical step-by-step approach to character creation and levelling up, dropping the character sheet straight onto the virtual tabletop, completed and ready to go. And it doesn’t take much longer to make a 10th level character than a 1st level one.

I wondered how the two character creators compared.

To be fair, it’s been a while since I used D&D Beyond for character creation and I know there’s been an update. So for curiosity and posterity, I decided to try creating two identical characters concurrently on both platforms.

Here’s how it went:

Roll20 versus D&D Beyond

• Step-by-Step Character Creation

Both character creation systems cite a step-by-step process which Roll20 claims ‘makes building a character simple and streamlined’.

D&D Beyond offers several options at this stage, but I’ll explore the quick build and randomize options later. For now, we’ll go with Standard with help text on.

• Getting Started

The next click had very different results. Roll20’s Charactermancer took me straight into choosing a race, whereas D&D Beyond gave me a host of customisation options.

While Roll20 waited patiently, I adjusted D&D Beyond’s settings to fit our campaign: Advancement Type from the default Milestone to XP, Hit Point Type from Fixed to Manual, and Encumbrance Type from Use Encumbrance to Variant Encumbrance. In Roll20, I know the encumbrance is handled elsewhere in the virtual tabletop. I’m not certain about the others.

• Choosing a race

The more polished presentation and matured development of D&D Beyond starts to become evident here, with subraces available in dropdowns, whereas Roll20 handles these choices a little later. I note that the Aasimar race and Eladrin Elf subrace are both available on D&D Beyond, but are absent on Roll20.

Beyond’s random name generator had decided we were called Bellenura, who sounds like a slightly edgy halfing to me, so let’s go with that on both platforms.

• Subrace

The two platforms handle subrace choice very differently. Roll20 has you choose a race, then presents you with the universal racial details and the relevant PHB excerpt in a sidebar, whereas Beyond has you choose the subrace from the outset and provided the details in a pop-up window.

Personally, I found Roll20’s presentation clearer and easier to navigate at this point. I opted for a stout halfling.

• Class/Review

Once again my attempts to compare like for like were confounded by Roll20’s eagerness to plow straight on to the next step, while Beyond provides the opportunity to review.

This is really a matter of taste, I suppose; it feels like Beyond is really savouring the creation process, whereas Roll20 wants it done so we can get on with the show.

• Choosing a class

D&D Beyond is again the more visually striking (notwithstanding Roll20’s use of PHB artwork), but both are functional. I was thinking Bellenura the stout halfing ought to be a rogue, but I wanted to see how spells are handled so maybe I’ll go for one of the mage types.

• Class details: Sorcerer

Not being that familiar with the distinction between the 5th edition spellflingers, I select Sorcerer first. Roll20 helpfully provides me with flavour text alongside the basic class details. Beyond keeps it simple. The flavour text wins me over to Sorcerer, given that it describes a halfling using stealth and spells together. Sold.

• Proficiencies

Choosing proficiencies and Bellenura’s Sorcerous Origin takes place on a single page for both systems, with Beyond highlighting where player choices are required with a blue/white exclamation mark.

Roll20 developed an odd bug at this point, repeating its request to choose two class-based skill proficiencies. In the interests of playtesting to destruction, I chose two additional ones on Roll20, then selected the Wild Magic origin on both platforms…

• Sorcerous Origin & (Beyond) Spells

…in doing so, both pages were populated with additional information.

I also noticed that the D&D Beyond layout featured a low profile, greyed-out dropdown option to choose spells which, when selected, opened out into a whole host of new options. I nearly missed that.

So while Beyond has me choosing my spells now, looking at Roll20’s progress bar at the top of its page, it’ll be a while before I do that in Roll20 (which is the norm, right? Is now the time to be choosing spells, before I’ve even rolled attributes or chosen a background?). In any case, Beyond’s spell selection process was simple and clear.

• Ability Scores

Finally, we get to the all important dice rolling bit!

Both systems offer the same options: standard array (15, 14, 13, 12, 10, 8), point buy (27 points), and manually rolling for stats. D&D Beyond doesn’t do RNG so I’ll generate and allocate the scores in Roll20 then manually copy them across to Beyond.

Roll20’s suggested abilities and class spellcasting ability reminders in the top bar were helpful. Beyond has more customisation though.

• Background

Bellenura’s edginess (as well as her stealth-related skills and spells) leant themselves well to the burglar background. For Roll20, this was a straightforward case of choosing from dropdowns or, in the case of personality traits etc. the option of determining randomly.

At this point, D&D Beyond pretty much presented me with fields for everything that hadn’t yet been done; character details like alignment, faith, lifestyle,as well as appearance and backstory. This makes sense off the back of choosing a background. I note that, while Beyond prompted me to choose skill proficiencies (stealth and one other), Roll20 didn’t. I assume this is because I chose too many earlier. Oops.

• Equipment

Both platforms offered a choice of equipment or gold. For brevity’s sake, I opted for the out-of-the-box class options. Irritatingly, Roll20 didn’t have any simple way of showing me what was included in the offered Dungeoneer’s and Explorer’s packs.

Completing this page showed D&D Beyond’s tendency to review and procrastinate in a good light, giving me a chance to assess my equipment.

• Does this spell the end?

Roll20 never really clarified what equipment Bellenura ended up with, instead rushing on to choose spells. D&D Beyond, however, declared that we were done. I chose the spells I’d opted for earlier in the Beyond process (aside from one which didn’t appear – I suspect that was a spell from a non-PHB source, which I thought I’d opted out of. Oh well.)

• Roll20 rolls onto Feats…

The feats page appeared for Roll20, ready for the levelling up process, but it pithily pointed out I hadn’t really done much yet to earn any.

• … then character details

Then we moved onto the character details D&D Beyond had bundled in with the Background section earlier.

• Final review

Roll20 finally presents you with a review page which is curiously light on detail. No clarity on my equipment was a notable omission. It did point out I’d missed choosing an alignment. How did I manage that? No doubt I’ll see it when I review the screenshots. Fortunately I was able to click on the ‘start’ button on the tracker along the top of the page and located the dropdown I missed (it was under ‘race’). I’m relieved to say that no details were lost in doing so and I was able to return to the review page to complete the character.

Unfortunately, this was also the point at which the ‘Building your character’ progress bar freezes for me, but I’ve figured out this seems to be an issue related to using a popout window rather than remaining on the Roll20 virtual tabletop environment.

I resolved it by closing the popout and finalising the process from an embedded pane.

Behold, the character sheets!

With all details completed in both systems, the character sheet’s sprung forth.

In D&D beyond’s case, there is an option for a four page PDF (page one shown) …

… but the main event is the interactive and customisable character sheet which is impressively slick and full featured.

It is also supported by a very tidy and usable smartphone interface.

I presume, therefore, that the same is true of tablets, which I would imagine would make perfect portable D&D Beyond character sheets for the real-world tabletop environment.

Like Beyond’s PDF, Roll20’s character sheet stays true to the original pen-and-paper character sheet.

It isn’t as pretty as D&D Beyond, but what it lacks in looks, it makes up for in functionality. Linked directly into its virtual tabletop, clicking any ability, proficiency, attack or other element prompts an appropriate virtual die roll.

The Charactermancer has still got a few kinks to shake out, but it works. And it is a welcome improvement to our online D&D experience.

Final Thoughts

The purpose of this comparison was to help me decide where to direct my future digital purchases. It might not make much sense to own a hardcopy and a digital copy of each D&D book, but it certainly makes zero sense to have multiple digital copies.

All things considered, I think my players have already decided for me. As much as I support the D&D Beyond project and think it’s a fantastic product, if it’s of less use to my players than an equivalent product that is integrated into the virtual environment that ties our game sessions together, then there is little point in be investing further in it.

That said, if our group were ever to decide to meet around an actual table, then I would absolutely push the D&D Beyond solution.

For now though, as Roll20 adopts more official Wizards of the Coast products, I’ll likely buy them if it will directly impact our virtual quality of life. I understand Xanathar’s Guide to Everything is already in the works and is certainly on my ‘to buy’ list in some format, and I would very much like to see a Roll20 Sword Coast Adventurer’s Guide.

Until then, I will nurture my dead tree editions. Except Xanathar’s, which I still need.

I suppose I’d better go change that lightbulb now. Remember the lightbulb?

I thought being a paramedic would help me cope with my parents’ deaths. Or even prevent them. I was wrong.

Allow me to explain.

When I first applied to Beds & Herts Ambulance & Paramedic Service in 2000, it was a partly a decision borne of a kind of naive, morbid curiosity. I was eager to take on what I thought to be a varied and challenging job, but I wasn’t entirely sure I was up to it. I wanted to test myself, and I wanted the self-respect that came with being able to cope with difficult scenarios.

In hindsight, I don’t think anyone is up to job in the beginning. Emergency ambulance work is the sort of occupation that no amount of training, preparation and advice can completely protect you from some of the tests to come. It’s a trial by (blood, shit and) fire* that can make you feel that you’re in over your head until you learn to cope.

[*disclaimer: fire is obviously the fire brigade’s remit, but the blood and shit is definitely all us.]

The teacher of those lessons is mostly experience, but the contribution of your colleagues – both peers and those senior – is also critical.

There’s a kind of unspoken tough love – a combination of hazing, camaraderie, and tactical neglect – that takes place between new recruits and veteran staff which ultimately leads you to a point where you can either cope with the pressures and responsibilities of death, life and everything in between (and to be honest, it’s mostly the in between), or you get out. There are also some who get to this point where they should get out and don’t, but that’s a topic for another day.

My point is that throughout my progress from naive and cocky trainee, through competent clinician to embittered veteran, and beyond to broken paramedic, I always content that, whatever happened, I was honing the skills and the mindset to be able to save my own when the time came.

The incentive was there on every attendance – but especially the cardiac arrests – to push for excellence, to go that extra mile, to leave no stone unturned because that’s what you’d want if it was your Mum or Dad.

In my mind, I’d frequently play out scenarios involving the collapse of a parent, working through all of the outcomes and eventualities like a scriptwriter exploring plot ideas or an actor endlessly rehearsing. All so I’d be prepared on the night.

The night never came.

Instead, in a cruel twist of fate, I’ve had to endure watching the unexpected early decline and death of both parents in long, drawn-out bedside vigils. In both cases they succumbed to diseases that ruined their minds before their bodies were ready to give up.

Those final hours watching their starved, dehydrated husks slowly shut down made a mockery of every life-saving skill I’d learned. I just had to watch, helpless, as the people who made me struggled and faded without saying goodbye.

Perhaps some of the softer skills came in useful during the ordeal; the ability to know when to do something, or when to do nothing. But knowing HOW to do nothing is harder. Knowing how to cope. I suspect these life moments are no more or less challenging whatever your background or training.

In any case, cope I did. But at a cost.

I withdrew from many aspects of my former life, including social media, in part because my participation was becoming a very negative experience which, without the security and validation that my parents provided me, had a far more profound effect. I found the social landscape of emotionally-led politics and 40th birthdays incendiary. Issues became more visceral, hurtful comments more harmful, my responses more aggressive. With the loss of the emotionally anchoring effect of my parents, I’d lost a maturity and stability that I never knew they provided.

And those who remained in my life seemed poor surrogates. Friends and acquaintances now seemed flawed, misguided, self-serving, hedonistic people making terrible decisions of a daily basis. I found contact with people I knew well resulted increasingly in feelings of disappointment, betrayal or disgust.

But the truth was that no one had changed dramatically. No one but me. The lens through which I saw the world had changed forever and I could only see the darkness and very little of the light.

It has been a brutally challenging emotional journey from the death of my Mum five years ago to my Dad’s laboured demise last Summer, punctuated by the ongoing struggles my younger sisters and their families face.

But in enduring, things seem somewhat brighter again.

Now, existing in this post-parent world far younger than I expected, I’ve learned to think around the inevitability and futility of existence, mostly by ignoring those facts. Just like starting out in the ambulance service, its a case of enduring until you find your feet.

I’ve been fortunate to have an amazingly tolerant and understanding wife, and two wonderful daughters who are all the motivation I need to try to be my best self. I’ve learned a lot about managing my failings. Keeping myself in check is no longer something I can outsource to my parents. I’ve entered an era of total responsibility which, while daunting, is also oddly freeing.

On reflection, coping is just what happens when you carry on.

Dear all,

As any of you who followed my teenage nephew’s brief, tragic foray into the Elite Dangerous community starlight likely already know, Michael (aka CMDR Michael Holyland) died on 22nd May 2019. 

His funeral service and cremation was on 7th June at which I gave two eulogies to remember Michael, to thank those who supported us and to help those attending process his end. 

But I have been very aware that not everyone who has been there for us was able to attend those services. In Michael’s last week of life, online a whole network of new friends sprang up in our darkest hour and made things more bearable with a magnificent display of empathy, kindness and creativity which I feel deserves to be recognised. 

I know that was Michael’s wish, so I’ve written this account of how Frontier and friends made the miserable, intolerable last days of a 15-year-old boy infinitely better.

Michael’s Last Week

On 14th May, I stood in Michael’s hospital room in Addenbrooke’s, Cambridge as I tried to process the inevitability of his forthcoming death. 

At that moment, he was perched on his hospital bed playing a racing game on his XBox, squinting at the screen obscured by his grotesquely swollen face. He was oblivious to his unavoidable fate. There was nothing more anybody could do for him; after almost six years of debilitating illness, all medical treatments and options had been exhausted or were no longer viable. We all just had to watch helplessly as this isolated, disabled and lonely autistic teenager unknowingly faced his final days. 

In an act of aimless despondence, I sent a tweet… and that started something bittersweet and amazing.

[I’d taken these photos earlier that day in the ‘teenager’s room’ where Michael had been allowed to set up his PC.]

It wasn’t long before I was contacted by Paige Harvey, a community manager at Frontier Developments, the studio behind Elite Dangerous. Paige had seen my tweet and wanted to do something to lift Michael’s spirits. She told me that she was scouring the office for ‘goodies to send’. At this point, I hadn’t made the gravity of Michael’s circumstances clear on Twitter – for good reason, Michael was pretty internet-savvy and we’d taken the decision to keep his terminal state from him to spare him avoidable emotional distress – but on learning that he only had a few days to live, Paige moved things up a gear. And then some.

The next day, she and her colleague Sally Morgan-Moore visited Michael on the oncology ward at Addenbrooke’s hospital and, as promised, brought a bag of swag including a poster signed by many of the Elite Dangerous team at Frontier. They stayed for a good while and were absolutely brilliant with Michael who could be quite abrupt and challenging at times. By the time they left, Michael was buzzing and eager to get the in-game gifts he’d been offered). I’d not seen him this elated for some time. Michael’s Dad, Karl, got the gifts framed and mounted on his wall.

And this was just the beginning of his brief but wonderful relationship with Frontier and friends. Michael would tell any passing nurse who cared to listen about his visit from ‘the people who make Elite’. Meanwhile, the outpouring of empathy and support continued from all quarters. Scores of fellow Elite Dangerous players sent their best wishes and offers of all kinds; authors Drew Wagar, Kate Russell, and their publisher Dan Grubb of Fantastic Books Publishing all got in touch; David Braben tweeted his best wishes.

Michael was loving the attention. I’d read him many of the supportive messages from various sources on Facebook, Twitter and elsewhere. Any messages which involved an invite to join a group, activity or expedition had him reaching for the voice comms. 

It was a difficult decision to know how much of this we could expose Michael to. His autism and life experiences for the past half-decade meant that his social tolerances were poor, so we’d always tried to discourage too much contact with ‘strangers on the internet’. But this was something special – the overwhelming kindness that was being shown by a videogame community was such a powerful, positive thing that it would have been a shame to keep Michael from it, especially given the stakes. 

I’d been helping Michael achieve one of his ambitions to stream his game activities, that was relatively manageable to police – especially with a viewership that largely just included Michael’s younger brother Nathan and friends.

I’d taken the opportunity presented by Paige and Sally’s visit to discuss how we might safely manage Michael’s engagement with the community and to field my concerns that we’d be involving lots of people in a story we already knew was going to end in tragedy. Paige assured me that it was something they were equipped to manage and so we set up a forum post which was carefully tended to by forum mod TJ (to whom I owe many thanks for his prudence, diligence and diplomacy).

The whole experience had Michael brimming with new-found energy reserves. In the day or so following the visit, he would spend hours either playing Elite or tinkering with ship designs in companion site, Coriolis.io.

His buoyant mood also led him to successfully managing to walk from the oncology ward all the way down to the food concourse, a feat he’d not managed for weeks. This was encouraging, because Paige had been back in touch with an invite for Michael to visit the Frontier Studios on the other side of Cambridge, which Michael had cheekily requested during their visit.

Frustratingly, Michael’s doctor had strongly advised against his departure from hospital, citing concerns that his lungs were too unstable and even the short trip to the food court may come at a price. This was a real blow, as Michael (and myself, to be honest) would have really enjoyed a tour of Frontier Towers.

Enter Zac Antonaci who, until this point, had been confining himself to being our most vocal and entertaining Twitch stream observer. He also happened to also be Paige’s boss at Frontier. He’d caught wind of Michael’s inability to visit and was looking at ways of bringing the tour to Michael. 

Not long after, in line with the doctor’s prediction, Michael deteriorated again, his facial swelling becoming so severe that it was difficult for him to open his eyes at all. Frustratingly, this meant his one available form of escapism was now under threat.

However, we had a backup plan. Drew Wagar had sent us the audiobook version of one of his Elite novels and Dan Grubb of Fantastic Books had followed up with giving us access to the rest of the Elite Dangerous back catalogue. Michael had already jokingly threatened to send his parents away for the weekend so he and I could binge-listen to them all. Now it was looking like that may be our only option for keeping Michael from going insane from being imprisoned inside his own broken body.

While nurses and Michael’s Mum, Laura, did what they could to reduce his swollen eye tissue, Michael refused to give up and was still somehow managing to peer at the screen enough to tinker with his Coriolis.io ship loadouts.

It was Saturday morning, three days after Paige and Sally’s visit, when Zac fielded an ambitious (ludicrous?) plan; ‘What if we could organise enough people to create a short story, set in the world of Elite where Michael was the hero. Something he could listen to and enjoy when he had difficulties with his vision, like now.’

It sounded like a wonderful idea, but the reality was that Michael’s lung deterioration was really starting to manifest now. The increasing pressure from air and fluid in the tissues around his throat meant that he had to constantly raise his chin to keep his airway open. He would occasionally have mini-choking episodes and was unable to move without becoming breathless.

At first I declined Zac’s offer, feeling that it would be an undertaking that would take more time than Michael had. But then Michael rallied and recovered enough to start making a hilariously ridiculous list of requests for his Elite account. Having already enjoyed being gifted a second account, dozens of skins, and access to new game content, he’d been emboldened and was now requesting a Tony Stark-style personal tower on a moon orbiting the planet Commander Picard had kindly discovered and named for him. A planet which he wanted moved closer to the human-populated ‘bubble’. And he was still managing to play a bit of Elite! I told Zac and we decided that he’d try to get something put together as quickly as possible.

Meanwhile Michael’s new-found fame had led to him make a few in-game contacts and we’d even been able to invite a couple of them onto the stream for some shared spaceship shenanigans. Special mention to Commander UselessED who Michael took a shine to and became something of a mentor for him (even though UselessED should have been studying for his GCSEs!).

On Sunday, Drew Wagar somehow managed to write a brilliant 7000 word script in a single day! (As an occasional writer myself, I’m personally in awe of this output.) 

By Monday, Zac had conscripted no fewer than three professional voice actors to record the story – much gratitude to Richard Reed, Jay Britton and Amelia Tyler (who deserves an award for driving for six hours in a day to get to the studio and back). On Tuesday, audio engineer Joe Hogan worked his magic to put it all together and by the evening, Zac and Paige were back at the hospital visiting Michael and playing him an exceptional piece of bespoke audio fiction which was preceded by a personal message from David Braben. 

Sitting in the hospital listening to it all with Michael was an epic, bittersweet experience. There were some lovely metaphorical nods to how Michael had faced his medical challenges and some of the more obvious references made his giant, puffy face beam with pride and happiness. 

The next day was Wednesday, the day Michael died.

We were streaming. Michael and I had been preparing for an expedition to obtain special Guardian modules for my ships and due to his new Elite celeb-filled Discord channel (encouraged by ‘Elite CEO’ Zac Antonaci), we’d just been joined by CMDR UselessED and CMDR Eid LeWeise.

Suddenly, Michael coughed and started to become distressed on comms, so I cut the stream, then after hearing Michael’s Mum shut his comms down, I made my apologies and left the channel, heading for hospital.

By the time I got there (I live about 45 minutes away), he’d been sedated and wasn’t expected to recover consciousness. His Mum, Dad and I took turns to sit with him and hold his hand. While I was with him, I played his Elite audio story again. Some of Drew’s words hit much harder the second time; ‘bravery, courage, unbowed in the face of overwhelming odds.’

He took his last breath peacefully a few hours later. We were all there.

Final Words

His end was unjust and tragic, but because of the heroic kindness of a videogame community, his last week of life was filled with an unexpected amount of happiness. For that, I am immensely grateful and I want to offer my eternal gratitude to everyone who contributed to that, from the players who stood ready to meet Michael online and those who took the time to send him an ‘o7’, to the Frontier staff and associates who gave so much of their time, compassion and creative energy.

It was Michael’s wish that the audiobook, Michael’s Story, should be shared with the Elite Dangerous community and I’ll talk with Zac & co. to see how best to go about this. I would dearly love Michael to be remembered in the best possible way.

On behalf of Michael and his family, thank you again, you magnificent humans, you make the world – and the internet – a better place.

Mat

My compulsion to stay working within the NHS is largely driven by guilt.

As a healthcare professional, nothing I have experienced in the last decade under a Conservative government gives me much hope that things are going to improve in urgent and emergency care any time soon, but I can’t bring myself to leave.

For reasons I think I understand in part, the electorate has deigned to give the reigns of power to a politician whose relationship with truth and principle is as flexible as the rejected man’s charisma and judgement isn’t.

I can do little but reflect upon the disappointment, concern and anxiety I feel for my country, my colleagues and my patients. I have no faith in the newly-elected prime minister’s pledges to invest in the NHS or to improve the lives of those most need it.

After a decade of under-investment in healthcare in England and Wales, the damage has been done and – much like the Tory manifesto pledge to replace most of the 21,000 police they drove away, any investment at this point will simply be bandaging over the scars of their own neglect.

The ideologies and values that gave us Austerity, Universal Credit, Windrush, Grenfell and Brexit have been endorsed, albeit reluctantly due to a political Hobson’s choice, by the country. This is who we are now. I must find a way to function under this yoke. If my fears are right, the underprivileged and the infirm will become more numerous and need help more than ever.

Perhaps I am in a position to walk away from the frustrations and inadequacies of healthcare in the UK today, but not everyone has that luxury. Many of my colleagues may be hanging on for their retirement, their health or their homes. And so we all try to hang on to our sanity.

The ever-increasing tide of patients struggling to find the right treatment in a withering healthcare system will not be helped by my departure, much less an exodus of healthcare professionals.

None of the above deserve to be neglected, abandoned or forgotten.

I begrudgingly recognise that I have a professional duty and so I convince myself to stay, in full recognition I’m likely to become burned out and abused by a country that has lost its way and a healthcare system that is doomed, but still needs me.

I watch, powerless, in the vain hope that our newly-emboldened right-wing, pro-brexit, morally dubious government might – against all expectations – give me reason to be positive.