[ISSUES CONTEST] Emergency Department Problems Ramping Up

[Klaus Devestatorie]

Inspired by constant ongoing issues in my state, where an ongoing campaign by the union representing paramedics was probably the biggest factor in a change of government last election. https://www.abc.net.au/news/2023-06-03/ ... /102436716

I've noticed there are plenty of issues about healthcare, but not so many about ambulances- and the few issues that do mention them are usually proposing privatization or a fix to accidentally banning ambulances along with other cars. Hoping this issue starts to plug a couple holes, I think there's room for other topics (i.e. response times of ambulances).

Fifth draft,
Renamed the issue so that the name of the issue does not include the word “issue”,
Reworded part of option 4.

Emergency Department Problems Ramping Up

Validity: Has universal health care policy, has automobiles, has capitalism.

The Issue: Emergency departments in @@NAME@@ are facing ever increasing demand, and ambulances with waiting patients are forced to queue until a bed is available. After a five hour wait caused a preventable death, your staff organised for you to visit a hospital yourself to try and diagnose the cause of the delays.

Option 1: Upon getting out of the car, you're immediately approached by @@RANDOMNAME@@, a driver next to a line of ambulances. "If you're here about that fatality, I can tell you right now that I've personally queued for a lot longer than five hours before. There's a dozen ambulances here and someone waiting in the back of all of them, and that means there's a dozen ambulance crews that can't save lives until there's space here to free us up again. I don't see how the hospital system can realistically cope without drastic expansion to emergency departments all over @@NAME@@."

Effect: sneezing too many times in a minute triggers an automatic doctors referral

Option 2: "There wouldn't be anything like the current delay for assistance if you let ED staff actually do our jobs properly", moans @@RANDOMNAME@@, an exhausted looking doctor slumped against the wall near the entrance. "Frankly, many of the people waiting for treatment don't have anything particularly serious. There's the occasional hypochondriac, but plenty of people who just have a sniffle. Hospital care needs to be saved for people who actually need to stay in a hospital. Can't we just tell people with minor issues to go somewhere else?"

Effect: public hospital staff roll their eyes at anything less than a heart attack

Option 3: "But you can't just turn me away! I can't go anywhere else!", shrieks @@RANDOMNAME@@, an elderly woman in the waiting area. "I'd absolutely visit a GP, but I'm retired, and it costs a ridiculous amount of @@CURRENCY@@ to speak to anyone other than the receptionist! This is the only place that won't demand payment up front. Surely you cover the fees at the private clinics for vulnerable people? It's not as if I like sitting here all day either!"

Effect: the fastest way to see a doctor is to quit your job and claim unemployment benefits

Option 4: Upon returning to your car, there's a call waiting for you from @@RANDOMNAME@@, a medical insurance executive with an eye for opportunity. "I know not everyone is keen on privatising any part of the system, especially hospitals, but it's a waste of our capabilities if we’re largely relegated to providing bundled healthcare coverage for the pre-existing government hospital network. There's no reason why we shouldn't be allowed to operate our own emergency departments for anyone willing to pay. It’s the simplest and cheapest solution- for the government, at least. Don’t overthink it.”

Effect: the first step in medical triage is determining the insurance details of the patient

Fourth Draft,
All options should now be generally funny,
Option 2 reworked to specify non-seriousness of conditions instead of just "didn't come by ambulance",
Option 3 reworked to merely specify "somewhere else" instead of private clinics,
Validity reworked to include capitalism.

Emergency Department Issues Ramping Up

Validity: Has universal health care policy, has automobiles, has capitalism.

The Issue: Emergency departments in @@NAME@@ are overloaded, and ambulances with waiting patients are forced to queue until a bed is available. After a five hour wait caused a preventable death, your staff organised for you to visit a hospital yourself to try and diagnose the cause of the problem.

Option 1: Upon getting out of the car, you're immediately approached by @@RANDOMNAME@@, a driver next to a line of ambulances. "If you're here about that fatality, I can tell you right now that I've personally queued for a lot longer than five hours before. There's a dozen ambulances here and someone waiting in the back of all of them, and that means there's a dozen ambulance crews that can't save lives until there's space here to free us up again. I don't see how the hospital system can realistically cope without drastic expansion to emergency departments all over @@NAME@@."

Effect: sneezing too many times in a minute triggers an automatic doctors referral

Option 2: "There wouldn't be anything like the current delay for assistance if you let ED staff actually do our jobs properly", moans @@RANDOMNAME@@, an exhausted looking doctor slumped against the wall near the entrance. "Frankly, many of the people waiting for treatment don't have anything particularly serious. There's the occasional hypochondriac, but plenty of people who just have a sniffle. Hospital care needs to be saved for people who actually need to stay in a hospital. Can't we just tell people with minor issues to go somewhere else?"

Effect: public hospital staff roll their eyes at anything less than a heart attack

Option 3: "But you can't just turn me away! I can't go anywhere else!", shrieks @@RANDOMNAME@@, an elderly woman in the waiting area. "I'd absolutely visit a GP, but I'm retired, and it costs a ridiculous amount of @@CURRENCY@@ to speak to anyone other than the receptionist! This is the only place that won't demand payment up front. Surely you cover the fees at the private clinics for vulnerable people? It's not as if I like sitting here all day either!"

Effect: the fastest way to see a doctor is to quit your job and claim unemployment benefits

Option 4: Upon returning to your car, there's a call waiting for you from @@RANDOMNAME@@, a medical insurance executive with an eye for opportunity. "I know not everyone is keen on privatising any part of the system, especially hospitals, but it's a waste of our capabilities if all we're really allowed to do is bundle healthcare coverage for @@MAJORINDUSTRY@@ employees. There's no reason why we shouldn't be allowed to operate our own emergency departments for anyone willing to pay. It's the simplest and cheapest solution- for the government, at least. Don't overthink it."

Effect: the first step in medical triage is determining the insurance details of the patient

Third Draft,
Corrected validity to require automobiles, and to require universal health care instead of a mixed system.
Resolved the player autonomy issue in the issue statement,
Reduced the number of queued ambulances in option 1 and replaced the paramedic with a driver,
Replaced the idea of referrals in option 2 with outright declining service,
Slight rewording of option 3.

Emergency Department Issues Ramping Up

Validity: Has universal health care policy, has automobiles.

The Issue: Emergency departments in @@NAME@@ are overloaded, and ambulances with waiting patients are forced to queue until a bed is available. After a five hour wait caused a preventable death, your staff organised for you to visit a hospital yourself to try and diagnose the cause of the problem.

Option 1: Upon getting out of the car, you're immediately approached by @@RANDOMNAME@@, a driver next to a line of ambulances. "If you're here about that fatality, I can tell you right now that I've personally queued for a lot longer than five hours before. There's a dozen ambulances here and someone waiting in the back of all of them, and that means there's a dozen ambulance crews that can't save lives until there's space here to free us up again. I don't see how the hospital system can realistically cope without drastic expansion to emergency departments all over @@NAME@@."

Effect: sneezing too many times in a minute triggers an automatic doctors referral

Option 2: "There wouldn't be anything like the current delay for assistance if you let ED staff actually do our jobs properly", moans @@RANDOMNAME@@, an exhausted looking doctor slumped against the wall near the entrance. "Frankly, most of the people inside right now didn't come by ambulance. There's the occasional hypochondriac, but plenty of people who just have a sniffle. Hospital care needs to be saved for people who actually need to stay in a hospital. Can't we just tell people with minor issues to go somewhere else?"

Effect: public hospital staff roll their eyes at anything less than a heart attack

Option 3: "But private clinics are the problem! You can't just turn me away!", shrieks @@RANDOMNAME@@, an elderly woman in the waiting area. "I'd absolutely go to a GP, but I'm retired, and it costs a ridiculous amount of @@CURRENCY@@ to speak to anyone other than the receptionist! This is the only place that won't demand payment up front. Surely you cover the fees at the private clinics for vulnerable people? It's not as if I like sitting here all day either!"

Effect: the fastest way to see a doctor is to quit your job and claim unemployment benefits

Option 4: Upon returning to your car, there's a call waiting for you from @@RANDOMNAME@@, a medical insurance executive with an eye for opportunity. "I know not everyone is keen on privatising any part of the system, especially hospitals, but it's a waste of our capabilities if all we're really allowed to do is bundle healthcare coverage for @@MAJORINDUSTRY@@ employees. There's no reason why we shouldn't be allowed to operate our own emergency departments for anyone willing to pay. It's the simplest and cheapest solution- for the government, at least. Don't overthink it."

Effect: the first step in medical triage is determining the insurance details of the patient

Second Draft,
Renamed the issue to clarify that it's an ED issue, not something wrong with the ambulances themselves,
Reworded option 1 to clarify that ramping damages response ability to other issues,
Reworded option 4,
Reworded the leading text to be somewhat snappier.

Emergency Department Issues Ramping Up

Validity: Any nation with a mixed healthcare system (i.e. neither fully private or public).

The Issue: Emergency departments in @@NAME@@ are overloaded, and ambulances with waiting patients are forced to queue until a bed is available. After a five hour wait caused a preventable death, you decided to visit a hospital yourself to try and diagnose the cause of the problem.

Option 1: Upon getting out of the car, you're immediately approached by @@RANDOMNAME@@, a paramedic next to a line of ambulances. "If you're here about that fatality, I can tell you right now that I've personally queued for a lot longer than five hours before. There's 26 ambulances here and someone waiting in the back of all of them, and that's 26 ambulance crews that can't save lives until there's space here to free us up again. I don't see how the hospital system can realistically cope without drastic expansion to emergency departments all over @@NAME@@."

Effect: The government is investing millions of @@CURRENCY@@ into new hospitals.

Option 2: "There wouldn't be anything like the current delay for assistance if you let ED staff actually do our jobs properly", moans @@RANDOMNAME@@, an exhausted looking doctor slumped against the wall near the entrance. "Frankly, most of the people inside right now didn't come by ambulance. I'm not claiming that people are just showing up with sniffles, but hospital care needs to be saved for people who actually need to stay in a hospital. Can't we just refer people to GPs?"

Effect: Public hospital staff roll their eyes at anything less than a heart attack.

Option 3: "But private clinics are the problem! You can't just turn me away!", shrieks @@RANDOMNAME@@, an elderly woman in the waiting area. "I'd absolutely go to a GP, but I'm retired, and it costs a ridiculous amount of @@CURRENCY@@ to speak to anyone other than the receptionist! This is the only place that won't demand payment up front. Can't you cover the fees at the private clinics for the vulnerable? It's not as if I like sitting here all day either!"

Effect: The fastest way to see a doctor is to quit your job and claim unemployment benefits.

Option 4: Upon returning to your car, there's a call waiting for you from @@RANDOMNAME@@, a medical insurance executive with an eye for opportunity. "I know not everyone is keen on privatising any part of the system, especially hospitals, but it's a waste of our capabilities if all we're really allowed to do is bundle healthcare coverage for @@MAJORINDUSTRY@@ employees. There's no reason why we shouldn't be allowed to operate our own emergency departments for anyone willing to pay. It's the simplest and cheapest solution- for the government, at least. Don't overthink it."

Effect: A two-tiered hospital system is emerging based on how wealthy the patients are.

Ambulance Issues Ramping Up

Validity: Any nation with a mixed healthcare system (i.e. neither fully private or public).

The Issue: Reports of ambulances being tied up at emergency departments due to a lack of ability to accept their patients have been simmering for some months. After reports of a five hour wait in an ambulance leading to a potentially preventable death filtered through to your office, you decided to visit the hospital yourself to try and understand the problem.

Option 1: Upon getting out of the car, you're immediately approached by @@RANDOMNAME@@, a paramedic next to a line of ambulances. "If you're here about that death, I can tell you right now that I've personally queued for a lot longer than five hours before. If this wasn't about life and death situations, I'd probably just shut up and claim the overtime, but there's someone in the back of all 26 of the ambulances out here. I don't see how the hospitcal system can realistically cope without drastic expansion to emergency departments all over @@NAME@@."

Effect: The government is investing millions of @@CURRENCY@@ into new hospitals.

Option 2: "There wouldn't be anything like the current delay for assistance if you let ED staff actually do our jobs properly", moans @@RANDOMNAME@@, an exhausted looking doctor slumped against the wall near the entrance. "Frankly, most of the people inside right now didn't come by ambulance. I'm not claiming that people are just showing up with sniffles, but hospital care needs to be saved for people who actually need to stay in a hospital. Can't we just refer people to GPs?"

Effect: Public hospital staff roll their eyes at anything less than a heart attack.

Option 3: "But private clinics are the problem! You can't just turn me away!", shrieks @@RANDOMNAME@@, an elderly woman in the waiting area. "I'd absolutely go to a GP, but I'm retired, and it costs a ridiculous amount of @@CURRENCY@@ to speak to anyone other than the receptionist! This is the only place that won't demand payment up front. Can't you cover the fees at the private clinics for the vulnerable? It's not as if I like sitting here all day either!"

Effect: The fastest way to see a doctor is to quit your job and claim unemployment benefits.

Option 4: Upon returning to your car, there's a call waiting for you from @@RANDOMNAME@@, a medical insurance executive with an eye for opportunity. "I know not everyone is keen on privatising the system, but it's a waste of our capabilities if all we're really allowed to do is bundled coverage for @@MAJORINDUSTRY@@ employees. There's no reason why we shouldn't be allowed to operate our own emergency departments for anyone willing to pay. It's the simplest and cheapest solution for you, at least. Don't overthink it."

Effect: A two-tiered hospital system is emerging based on how wealthy the patients are.

[Kaschovia]

The Issue: Reports of ambulances being tied up at emergency departments due to a lack of ability to accept their patients have been simmering for some months. After reports of a five hour wait in an ambulance leading to a potentially preventable death filtered through to your office, you decided to visit the hospital yourself to try and understand the problem.

The description could be worded slightly clearer, for example: "Tensions are at an all-time high in the overflowing hospitals of @@NAME@@ as countless ambulances, tied up at emergency departments, are unable to treat patients quick enough. After a five hour wait led to a preventable death, you decided to visit one of the hospitals yourself to understand the problem."

[Kathol Rift]

Not an issue author, but am an EMT, and let me just say that you hit the nail directly on the head with the accuracy of the situation and characters. I salute you from waiting on the ER wall for the charge nurse to get to me with a room number.

[Klaus Devestatorie]

The Issue: Reports of ambulances being tied up at emergency departments due to a lack of ability to accept their patients have been simmering for some months. After reports of a five hour wait in an ambulance leading to a potentially preventable death filtered through to your office, you decided to visit the hospital yourself to try and understand the problem.

The description could be worded slightly clearer, for example: "Tensions are at an all-time high in the overflowing hospitals of @@NAME@@ as countless ambulances, tied up at emergency departments, are unable to treat patients quick enough. After a five hour wait led to a preventable death, you decided to visit one of the hospitals yourself to understand the problem."

Thanks, I'll re-word this and other unclear sections. To be clear, it's the hospitals unable to accept patients quickly enough, not the ambulances unable to get there- but too many ramped ambulances does have knock on effects for responses, so I'll try and work that in too.

Not an issue author, but am an EMT, and let me just say that you hit the nail directly on the head with the accuracy of the situation and characters. I salute you from waiting on the ER wall for the charge nurse to get to me with a room number.

Thank you for your vital work, and I'm glad to hear I'm on the right track.

[Electrum]

I think there's some good writing here and you're on the right track.

Remember, effect lines are supposed to be punchlines, so I suggest reviewing them for 1 and 4.

For option 2, isn't referring people to general practitioners already being done? When a patient gets to the emergency room, they are triaged. If they are low priority they are dealt with last. In Australia, the government is trying to fix this by funding primary care centres for people who need urgent care but not an emergency response which is what you have in option 3. Second effect line is very good though.

[Klaus Devestatorie]

I think there's some good writing here and you're on the right track.

Remember, effect lines are supposed to be punchlines, so I suggest reviewing them for 1 and 4.

For option 2, isn't referring people to general practitioners already being done? When a patient gets to the emergency room, they are triaged. If they are low priority they are dealt with last. In Australia, the government is trying to fix this by funding primary care centres for people who need urgent care but not an emergency response which is what you have in option 3. Second effect line is very good though.

For option 2, I feel like we can safely assume there is triage in a hospital, as that's normal medical practice no matter where you are in the world, but I'm not sure you can assume that an ED doctor has the authority to tell a patient that their issue is too insignificant for the hospital while still simultaneously accepting that it's appropriate to get some sort of care elsewhere for it. For option 3, in the Australian context, I feel like I'm more referring to the concession card system (HCC, PCC, CSHCC etc), and that option 2 might be more appropriate for funding primary care centres. The difficulty with interpreting either option as funding primary care centres is that then you have to still somehow distinguish actual policy effect ingame vs option 1.

[Verdant Haven]

- Good topic. Your description is clean and succinct. The one element I want to call out in the description is to not inform Leader what they decided to do (player autonomy problem). Instead, get them to the hospital in some other way (eg: "a tour of a local hospital was arranged..." or "you were invited to...")

- Additional issue validity: has automobiles

- Apologies in advance for a long incoming discussion of scale. 26 ambulances (these being treated as ALS ambulances in particular) is more than exist in many entire cities. While it's nothing compared to massive and well-funded place like New York City or London, which have around 450 ambulances each, your average city of 500,000-1,000,000 is not likely to have an ALS capacity as big as is represented in the draft. The other side of this is that any metro with the capacity to line up 26 ALS units at a single hospital is also the sort of metro that will have numerous hospitals available. New York and London have hundreds of medical facilities each, with a sizeable handful of major hospitals among them! Hospitals will initiate diversion when they approach the point their ER/ED/AE can't take another patient, which means they recommend that ambulances simply go elsewhere. This is not to say the delays aren't real – they very much are. They tend to occur in somewhat smaller and less-well-served areas though (Rochester, NY has a big problem with this – population ~200k), where there are fewer crews, fewer places to take patients, and keeping a single crew busy has a greater proportional impact on available services. That's all a very long way of saying that I think this is a great topic, but I would reduce that count to maybe 2 or 3 ambulances waiting, and make some reference to the fact that this is a bigger issue in less-served areas.

- Option 1: Would it make more sense for the person approaching Leader to perhaps be the driver of one of the waiting ambulances, rather than the paramedic? Presumably if they're waiting with a critically ill patient, the paramedic is with the patient trying to keep them alive.

- Option 2: If I understand the real-world problem correctly, much of it is to do with freeing up beds in the ER being a very time-consuming process that involves coordinating a lot of moving parts. In order to have this option feel like it actually addresses the problem, I think the request needs to be a little stronger. Referring to GPs wouldn't really take the pressure off, because that still involves the ED taking in the patient, assessing them, and generating a referral, which takes hours. I think it would be stronger to have the request be something like permission to refuse ER use to those with obviously non-emergency conditions, insisting that they seek some other means of care. The argument could also be strengthened by acknowledging that some people *do* just show up with the sniffles – "non-emergency" visitors to the ER can be everything from earnestly loving concern (like parents whose baby cried more than usual and they want to be sure) to "frequent fliers" like hypochondriacs or those who need a place to be warm.

- Option 4: I'm confused by. As the validity here suggests a mixed public/private healthcare system, I'm not sure how this suggests something different. This is exactly what private hospitals are.

- Effect lines aren't sentences. No capitals, no periods.

[Klaus Devestatorie]

- Good topic. Your description is clean and succinct. The one element I want to call out in the description is to not inform Leader what they decided to do (player autonomy problem). Instead, get them to the hospital in some other way (eg: "a tour of a local hospital was arranged..." or "you were invited to...")

- Additional issue validity: has automobiles

- Apologies in advance for a long incoming discussion of scale. 26 ambulances (these being treated as ALS ambulances in particular) is more than exist in many entire cities. While it's nothing compared to massive and well-funded place like New York City or London, which have around 450 ambulances each, your average city of 500,000-1,000,000 is not likely to have an ALS capacity as big as is represented in the draft. The other side of this is that any metro with the capacity to line up 26 ALS units at a single hospital is also the sort of metro that will have numerous hospitals available. New York and London have hundreds of medical facilities each, with a sizeable handful of major hospitals among them! Hospitals will initiate diversion when they approach the point their ER/ED/AE can't take another patient, which means they recommend that ambulances simply go elsewhere. This is not to say the delays aren't real – they very much are. They tend to occur in somewhat smaller and less-well-served areas though (Rochester, NY has a big problem with this – population ~200k), where there are fewer crews, fewer places to take patients, and keeping a single crew busy has a greater proportional impact on available services. That's all a very long way of saying that I think this is a great topic, but I would reduce that count to maybe 2 or 3 ambulances waiting, and make some reference to the fact that this is a bigger issue in less-served areas.

- Option 1: Would it make more sense for the person approaching Leader to perhaps be the driver of one of the waiting ambulances, rather than the paramedic? Presumably if they're waiting with a critically ill patient, the paramedic is with the patient trying to keep them alive.

- Option 2: If I understand the real-world problem correctly, much of it is to do with freeing up beds in the ER being a very time-consuming process that involves coordinating a lot of moving parts. In order to have this option feel like it actually addresses the problem, I think the request needs to be a little stronger. Referring to GPs wouldn't really take the pressure off, because that still involves the ED taking in the patient, assessing them, and generating a referral, which takes hours. I think it would be stronger to have the request be something like permission to refuse ER use to those with obviously non-emergency conditions, insisting that they seek some other means of care. The argument could also be strengthened by acknowledging that some people *do* just show up with the sniffles – "non-emergency" visitors to the ER can be everything from earnestly loving concern (like parents whose baby cried more than usual and they want to be sure) to "frequent fliers" like hypochondriacs or those who need a place to be warm.

- Option 4: I'm confused by. As the validity here suggests a mixed public/private healthcare system, I'm not sure how this suggests something different. This is exactly what private hospitals are.

- Effect lines aren't sentences. No capitals, no periods.

In order,

-Will correct the player autonomy issue;
-Is there no exemptions to has automobiles for ambulances alone? Can add anyway.
-I can tone down the number listed, but 450 sounds astonishingly short for London or NYC. My state operates 270 ambulances, the vast majority of which would be in Adelaide, a metro area comparable to Buffalo-Niagara MSA in size and population. I've seen reported as many as 10 ambulances ramped at a single hospital here just this year, and it was neither our largest hospital nor at the peak of the issue. I suspect 26 is closer to the mark than 2 or 3 on many nights.
-I can swap to an ambulance driver and reconsider option 2, but I'm not familiar with the concept of a private hospital having a large emergency department. This again may be an America vs rest of world thing.

[Kathol Rift]

- Good topic. Your description is clean and succinct. The one element I want to call out in the description is to not inform Leader what they decided to do (player autonomy problem). Instead, get them to the hospital in some other way (eg: "a tour of a local hospital was arranged..." or "you were invited to...")

- Additional issue validity: has automobiles

- Apologies in advance for a long incoming discussion of scale. 26 ambulances (these being treated as ALS ambulances in particular) is more than exist in many entire cities. While it's nothing compared to massive and well-funded place like New York City or London, which have around 450 ambulances each, your average city of 500,000-1,000,000 is not likely to have an ALS capacity as big as is represented in the draft. The other side of this is that any metro with the capacity to line up 26 ALS units at a single hospital is also the sort of metro that will have numerous hospitals available. New York and London have hundreds of medical facilities each, with a sizeable handful of major hospitals among them! Hospitals will initiate diversion when they approach the point their ER/ED/AE can't take another patient, which means they recommend that ambulances simply go elsewhere. This is not to say the delays aren't real – they very much are. They tend to occur in somewhat smaller and less-well-served areas though (Rochester, NY has a big problem with this – population ~200k), where there are fewer crews, fewer places to take patients, and keeping a single crew busy has a greater proportional impact on available services. That's all a very long way of saying that I think this is a great topic, but I would reduce that count to maybe 2 or 3 ambulances waiting, and make some reference to the fact that this is a bigger issue in less-served areas.

- Option 1: Would it make more sense for the person approaching Leader to perhaps be the driver of one of the waiting ambulances, rather than the paramedic? Presumably if they're waiting with a critically ill patient, the paramedic is with the patient trying to keep them alive.

- Option 2: If I understand the real-world problem correctly, much of it is to do with freeing up beds in the ER being a very time-consuming process that involves coordinating a lot of moving parts. In order to have this option feel like it actually addresses the problem, I think the request needs to be a little stronger. Referring to GPs wouldn't really take the pressure off, because that still involves the ED taking in the patient, assessing them, and generating a referral, which takes hours. I think it would be stronger to have the request be something like permission to refuse ER use to those with obviously non-emergency conditions, insisting that they seek some other means of care. The argument could also be strengthened by acknowledging that some people *do* just show up with the sniffles – "non-emergency" visitors to the ER can be everything from earnestly loving concern (like parents whose baby cried more than usual and they want to be sure) to "frequent fliers" like hypochondriacs or those who need a place to be warm.

- Option 4: I'm confused by. As the validity here suggests a mixed public/private healthcare system, I'm not sure how this suggests something different. This is exactly what private hospitals are.

- Effect lines aren't sentences. No capitals, no periods.

In order,

-Will correct the player autonomy issue;
-Is there no exemptions to has automobiles for ambulances alone? Can add anyway.
-I can tone down the number listed, but 450 sounds astonishingly short for London or NYC. My state operates 270 ambulances, the vast majority of which would be in Adelaide, a metro area comparable to Buffalo-Niagara MSA in size and population. I've seen reported as many as 10 ambulances ramped at a single hospital here just this year, and it was neither our largest hospital nor at the peak of the issue. I suspect 26 is closer to the mark than 2 or 3 on many nights.
-I can swap to an ambulance driver and reconsider option 2, but I'm not familiar with the concept of a private hospital having a large emergency department. This again may be an America vs rest of world thing.

I'll weigh back in for the ambulance volume thing, I was assuming the number was mostly hyperbole for the nature of NS issues often exaggerating issues. The largest ambulance bay in my city will hold maybe 15 ambulances at once in the actual spaces, more than that just packed into whatever open asphalt they can find. I've never seen more than around 8 at a time there, sometimes with a couple fire engines and several police vehicles as well. And that is already way more than a lot of hospitals are prepared to deal with at once, and that's in a city with way more hospitals than is the norm, so our overcrowding and wait time issues aren't quite as bad as a lot of other places. We'll still hug the wall for nearly an hour sometimes depending on the triage level of our patient. Critical patients get priority obviously, but sometimes there's just plain not beds for them either.

[Klaus Devestatorie]

Third draft up. After some thought, I've decided I like option 4 too much the way it is to change it drastically, and instead I'm adjusting the validity. I can see there's a universal health care policy, but I'm not sure that means that *only* the state provides healthcare. If that's not the case, it may need adjustment to also require a small insurance industry or high public healthcare spending.

[Southland]

I feel like Option 1 could use a more punchier result. Maybe something like "a hospital is built whenever someone blows their nose"

[Australian rePublic]

Option 2- Why are they going to hospitals with minor issues?

[Klaus Devestatorie]

Option 2- Why are they going to hospitals with minor issues?

It actually happens a lot. Some people can't afford GP fees or secure an appointment within a reasonable time frame. Some people are overestimating their condition, etc. If you're in Australia you've probably seen a state government ad campaign by now telling people not to go to the ED unless it's an actual emergency, and they spend that money because it's a problem.

I've now got "funny" effect lines for options 1 and 4, and I'm generally happy with the issue; waiting to see if there's any other feedback before submitting later this month.

[Verdant Haven]

This keeps getting better – nice work.

- Option 2: Is the statement "most of the people inside right now didn't come by ambulance" intended to be understood as "most of the people inside right now don't have serious conditions" by the player? I'd probably adjust to say something like that, as people with genuinely dangerous conditions can/do show up by other means.

- Option 3: The speaker appears to be reacting to a suggestion that is no longer made – attending private clinics. The basic response is fine, but might need to have the exact language tweaked to account for the new phrasing of Option 2.

- With the Universal Healthcare validity in place, Option 4 works for me now. The only thing I question is the comment about bundling coverage for @@MAJORINDUSTRY@@ employees. With UHC, everybody would have some kind of access to manage, not just the largest industry.

- Option 4 is a capitalist option – probably needs a capitalism validity on it

[Klaus Devestatorie]

This keeps getting better – nice work.

- Option 2: Is the statement "most of the people inside right now didn't come by ambulance" intended to be understood as "most of the people inside right now don't have serious conditions" by the player? I'd probably adjust to say something like that, as people with genuinely dangerous conditions can/do show up by other means.

- Option 3: The speaker appears to be reacting to a suggestion that is no longer made – attending private clinics. The basic response is fine, but might need to have the exact language tweaked to account for the new phrasing of Option 2.

- With the Universal Healthcare validity in place, Option 4 works for me now. The only thing I question is the comment about bundling coverage for @@MAJORINDUSTRY@@ employees. With UHC, everybody would have some kind of access to manage, not just the largest industry.

- Option 4 is a capitalist option – probably needs a capitalism validity on it

Updated based on this feedback- the only thing I haven't implemented with the change to not specify @@MAJORINDUSTRY@@- the idea is that with UHC, only very wealthy businesses are bothering to offer private options for their employees. I might reword in a few days that to better state that.

[The Ferret Lands]

Is it mean of me to say I think the title is a little long and boring? Unless ramping up refers to something I'm not getting?
Haven't come up with any better ambulance puns yet but I'm working on it.

[Klaus Devestatorie]

Is it mean of me to say I think the title is a little long and boring? Unless ramping up refers to something I'm not getting?
Haven't come up with any better ambulance puns yet but I'm working on it.

In this case, ramping is the name for when an ambulance is forced to wait outside the hospital with a patient because there's no room for the hospital.

[Verdant Haven]

Updated based on this feedback- the only thing I haven't implemented with the change to not specify @@MAJORINDUSTRY@@- the idea is that with UHC, only very wealthy businesses are bothering to offer private options for their employees. I might reword in a few days that to better state that.

Ahhhh, ok - I definitely missed what was being intended there. If there is some way to clarify that what's being referred to are "extra" perks/health care options for industry leaders, above and beyond the national program, I do think that would help.

In this case, ramping is the name for when an ambulance is forced to wait outside the hospital with a patient because there's no room for the hospital.

I do like this pun, but I can see how it might get missed. Two minor thoughts to help with that, if you're so inclined:

- Drop "Issues" from the title, so it's formatted more like your original version.
- Include a couple words in the description that include the word "ramp" to hint at what it means. Something along the lines of "...and ambulances with waiting patients are forced to queue on the ramp until a bed is available."

[Klaus Devestatorie]

Fifth draft. I can't figure out a way to add the phrase "ramping" into the issue opening text that I like. I don't like the phrase "waiting on the ramp"- who says they're specifically on a ramp? They might be in a car park, blah blah. I have reworded option four so that the "waste of our capabilities" is more direct to the issue at hand, and renamed the issue to drop the word "issue" from the title.

Further feedback is still welcome- if I get none by the end of the weekend, I intend to submit.

[Klaus Devestatorie]

Nearly forgot, but I have now submitted it. Fingers crossed.

[Australian rePublic]

Option 2- Why are they going to hospitals with minor issues?

It actually happens a lot. Some people can't afford GP fees or secure an appointment within a reasonable time frame. Some people are overestimating their condition, etc. If you're in Australia you've probably seen a state government ad campaign by now telling people not to go to the ED unless it's an actual emergency, and they spend that money because it's a problem.

I've now got "funny" effect lines for options 1 and 4, and I'm generally happy with the issue; waiting to see if there's any other feedback before submitting later this month.

Don't explain here, explain in the issue