Written Evidence to the National Assembly for Wales’ Health and Social Care Committee, November 2015 to Inform the Follow Up Inquiry Into the Performance of the Ambulance Services in Wales
The GMB has responded to each of the eight areas that the committee identified in its original inquiry into the performance of Ambulance Services in Wales, in the order that the letter was sent to the Deputy Minister for Health, Vaughan Gething.
Conclusion 1 : The Emergency Ambulance Services Committee, the Welsh Ambulance Services NHS Trust and local health boards must work together urgently to improve emergency ambulance response times and optimise patient outcomes. Performance measures must be clinically appropriate and take sufficient account of patient outcomes. Therefore the work announced by the Minister for Health and Social Services to review ambulance response measures should be rapid, clinically-led, informed by best practice and designed to enable benchmarking across the UK where possible.
Performance Indicators
Since the report the clinical response model has changed and a trial of a clinically led response outcome has been introduced from the 1st October 2015. Data is now being collated to ascertain what best practise should be. As an organisation, the GMB completely supports this trial, however, we are concerned that the appropriate training to support the clinicians (i.e. paramedics) is still not in place. We believe that this training is essential for this model to succeed.
Conclusion 2 : To maintain momentum and work towards a whole system approach to unscheduled care, all health boards must be fully engaged with the work of the Welsh Ambulance Services NHS Trust through the work of the Emergency Ambulance Services Committee on a national level, and directly with the Trust on a local level. Health boards must take due account of the impact on the Welsh Ambulance Services NHS Trust when developing new services or considering making changes to existing services. Health boards must also ensure that the Welsh Ambulance Services NHS Trust is involved in discussions at a sufficiently early stage to enable it to give proper consideration to the impact on its services.
Accountability & Engagement
Whereas the GMB accepts and welcomes these proposals and recommendations we are currently unable to comment on how they have progressed as we have not been approached to be involved in this process so far.
Conclusion 3 : Agreement must be reached between the Welsh Ambulance Services NHS Trust, trades unions and staff at the earliest opportunity on revised staff rosters in those parts of Wales for which revised arrangements are not yet in place. The Welsh Ambulance Services NHS Trust must, working in partnership with trades unions and staff, put in place arrangements to review staff rosters at appropriate intervals to avoid future mismatches between staffing and anticipated demand.
Leadership, Organisational Change & Staffing
The roster reviews have been started and are currently on-going, however, the GMB has raised concerns with WAST that in some areas new rotas have been signed off by management that have not been agreed in partnership and have failed to follow the agreed process. We have also raised concerns where we believe that the priority for rota charge is financially led and not necessarily to the benefit of either patients or the health and wellbeing of the staff.
With regard to the new arrangements that were put in place in the Cardiff & Vale, Cwm Taf and Aneurin Bevan Health Board areas we can make the following comments;
Cardiff & Vale:- Rota’s were implemented, however, they were not agreed in partnership and did not follow the agreed process. The end product of this is that the response targets worsened in that area but a financial saving was made. This is currently being investigated by the Trust. The GMB has not been asked to participate in this process.
Cwm Taf:- This locality has seen the introduction of ring fencing of resources which has had a positive effect on targets and staff morale. The trial has significantly increased the number of vehicles available by utilising external companies to supplement the existing resources.
Morale has improved due to crews now being able to take rest breaks more appropriately/regular and there has been a clear reduction in shift overruns.
Aneurin Bevan:- At Aneurin Bevan the rotas are still being worked on in partnership and both the management and Trade Unions have questioned the data as it is suggesting that a reduction in resources is required. However, the current response targets are not being met and by reducing resources the problem will get worse. In the meantime the Trust is looking to fill vacancies wherever possible but this will take time to take effect.
Of the three examples given the Cwm Taf model is clearly, based on evidence produced during the trial, the indicator for best practice, based on the correct available resources.
The suggestions that recruitment of additional staff will help to facilitate revised rotas we believe is yet to be seen. We believe that the £7.5 m investment has prevented the service from falling backwards but, without further investment, will not enable the service to move forward.
Whereas we welcome the ambulance services commissioner developing the “demand and capacity” tool we would appreciate being involved in that development but to date we have not been asked to be involved.
Conclusion 4 : The Welsh Ambulance Services NHS Trust must prioritise emergency ambulance services provision. Work is required to identify appropriate mechanisms for the provision of non-emergency patient transport services, and to disaggregate those services from the Trust in accordance with recommendation 2 of the McClelland Review. The Trust must establish a clear plan for the disaggregation, with identified timescales and costs. The Committee expects to receive an update on this plan before it follows up its inquiry later this year.
Non Emergency Patient Transport
The GMB still has concerns around the disaggregation of patient transport services as we identified to Mark Drakeford, Minister for Health, after the publication of the McClelland review.
Part of our concern was that the GMB as an organisation had been left out of the review and were not invited to give evidence. Furthermore it was evident that the National Programme Board which was dealing with the patient transport services at the time had not reached a conclusion to disaggregate the service and had not been asked to take part in the McClelland review, in fact, the National Programme Board findings were contrary to the McClelland findings. However, there has been progression and the GMB understands that discussions are on-going and a final business case has been submitted to the minister outlining a partnership view on how the service should evolve. This business case would see patient transport services run hand in hand with the Emergency Medical Services (EMS).
Conclusion 5 : The Emergency Ambulance Services Committee, the Welsh Ambulance Services NHS Trust and local health boards must work together to reduce the number of hours lost as a result of patient handover delays. The new handover policy must be implemented consistently across Wales, and any issues identified in the follow up visits made by the chief executive-lead on unscheduled care must be resolved swiftly.
Patient Handover
Patient Handover continues to be an issue especially when the system is under pressure. The GMB welcomes all attempts by Health Boards and Trusts to improve on handover times but we feel that such improvements are not within the gift of the Ambulance Service.
Conclusion 6 : The Chief Ambulance Services Commissioner, the Emergency Ambulance Services Committee and the Welsh Ambulance Services NHS Trust should urgently address the issue of ambulances being ‘pulled away’ from their areas. In doing so, they should seek to identify and learn from best practice across the UK. The ‘return to footprint’ pilot should be explored and evaluated on a wider basis as a priority.
Models of Development
The GMB totally supports this principle, as referred to in conclusion 2. We would support this model being rolled out across the service. However, to do so would require additional resources.
Conclusion 7 : In providing unscheduled care, health boards and the Welsh Ambulance Services NHS Trust must take account of the patient’s individual needs. Health boards and the Welsh Ambulance Services NHS Trust must ensure that assessment, care and treatment are provided in ways which meet the patient’s individual needs, and help them achieve their optimum outcome. This should include appropriate use of assessment, care and treatment provided in the community, as well as hospital-based provision.
Frequent Callers
The GMB totally supports this conclusion. However, for this to work sufficient resources need to be allocated WAST to fully educate staff across the organisation i.e. frontline, control, NHSD/111 Services etc. Without the additional skills it is not possible to effectively supply the service requirements, nor would it be safe to do so.
Conclusion 8 : Ambulance services in the medium and longer term must be high performing, and aligned to demand. Therefore health boards, the Emergency Ambulance Services Committee and the Welsh Ambulance Services NHS Trust should undertake robust and effective forward planning which takes anticipated demographic changes into account.
Anticipation the Demand for services
We support this move to a three year development plan and we are happy to assist with this process wherever we can.
Paul Gage
Lead NHS Officer
GMB Wales and South West November 2015