Unites Submission to the Social Care Committee

November 2015

Introduction

Unite has some 6000 members in the heath sector in wales. Of that we have some 600 in the Ambulance service covering all aspects of the service.

The submission below is intended to give our initial responses to the submission made by the Minister and will follow the same sequence of responses that he has made.

We look forward to discussing these matters further and expanding on our responses where required when we meet on 3rd December.

Comments on the Ministers Response

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.

This was a clear recommendation in the McClelland Review and I welcome the committee’s support for the review of ambulance response time targets. The existing eight-minute target is based on data from studies published more than 40 years ago which focused on the treatment of out-of-hospital cardiac arrest only. It is important to note the studies did not consider any other type of pre-hospital emergency condition, and there is little empirical research available on response times to any other type of emergency calls. I was particularly encouraged to note the committee’s support for ensuring that patients receive services appropriate to their need which aligns directly to the principles of prudent healthcare. This should be the key driver in an emergency clinical response.

It is important we continue to develop clinical performance and patient outcomes as the main standards for assessing the performance of emergency ambulance services to meet public expectation of accountability and transparency.

Unite still feels there is inequity in rural areas and that there is understaffing at all grades. Resources are pulled out of rural areas to service the more urban areas, this whirlpool effect is created by higher demand in these areas and therefore more calls can be hit in 8 minutes. There are less options for patients as to where they can get seen if hospital admission is not necessary. Many minor injury units are only open during day time working hours therefore travel to the nearest DGH is the only option. Rural communities are therefore let down both on timeliness and their experience of the service provided, not just by WAST but by the wider NHS.

For Ambulance staff this is exacerbated by poor rest break management which is caused in our view by low staff levels as is the ability of crews to finish on time.

In addition rural crews have to deal with high travel mileage as well as issues such as no time to meet with line manager, be able to take up training opportunities, manage infection control.

As a result there are high sickness levels some due to irregular meals, as well as musculoskeletal issues due, we believe, to long time spent in vehicles as well as linked to manual handling. In our experience the stress and burnout staff suffer is on the increase as staff have to cope with an ever increasing workload and higher public expectations while staff numbers remain relatively static.

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.

There has been considerable progress in the level of responsibility for emergency ambulance services at a local level among health boards. This is central to embedding the ambulance services in the unscheduled care system. The early agreement on WASTs budget for 2015/16 is tangible evidence of progress in this area and a step change in the collaboration between health boards and the Trust.

The emergency ambulance service’s national collaborative commissioning quality and delivery framework drives accountability and responsibility among health boards through a range of actions. This includes the requirement for the nomination from each health board of an Emergency Ambulance Services ‘Champion’ to act as their organisation’s point of contact for the successful operation and ongoing development of the framework. A collaborative performance delivery group which reports directly to EASC has been established and will consider and advise on the management of performance issues. This will include chief operating officers from each health board and will be chaired by the Chief Ambulance Services Commissioner.

Health board chairs and independent members receive regular updates and progress reports from their own executive directors and will invite WAST to attend board meetings or sub-committees. The chair of EASC and the chief ambulance services commissioner will attend each health board meeting at least once annually.

The framework, which includes a number of joint measures, will also enable both WAST and health boards to detail how they will support improvements to ambulance responsiveness and quality of delivery within their integrated medium term plans.

I have received formal assurance from Dr CDV Jones, chair of Cwm Taf University Health Board that all health boards are committed to achieving this objective. In view of the committee’s recommendation I will seek further assurance from chairs of health boards that the momentum achieved to date is fostered at all levels. I will also seek assurance from all health boards about their processes for ensuring all relevant stakeholders, including WAST, are engaged in discussions about service change proposals at an early stage.

This response in our view is all at the very high level of the service and we feel not reflected at ground level.

Ambulances waiting outside hospitals is now a daily occurrence and has not improved significantly at all. Because our provision of resources is tightly aligned to predicted demand, having vehicles unable to respond has a knock on effect on other vehicles travel to scene times and contributes to the whirlpool effect mentioned in the previous point.

Our members are still struggling to get direct access to wards with some patients. Everything has to go via ED which creates a bottle neck and they are experiencing delays in admission wards as well as ED.

Indeed Admission wards seem to be becoming another bottle neck in the system as all patients, be they direct GP admissions or ED admissions, have to go through an admission ward for assessment. Because of a lack of capacity (no beds) crews are regularly kept waiting in the corridor.

Conclusion 3

Agreement must be reached between the Welsh Ambulance Services NHS Trust, trade 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.

Aligning frontline staffing capacity to meet predicted levels of demand is central to improving ambulance responsiveness. New arrangements are in place in the Cardiff and Vale area, and revised arrangements are due to be implemented in the Cwm Taf and Aneurin Bevan health board areas by the end of May.

Discussions are ongoing in regard to staff rosters in the Abertawe Bro Morgannwg, Betsi Cadwaladr, Hywel Dda and Powys areas. The quality and delivery framework requires WAST to reduce reliance on overtime and this will in itself act as a driver to ensure robust staff rosters are in place for frontline and clinical contact centre staff. EASC invested £7.5m to support the recruitment of additional staff which helps facilitate the revised rosters.

The chief ambulance services commissioner has commissioned the development of a ‘demand and capacity’ tool by Cardiff University, in collaboration with Aneurin Bevan health board’s continuous improvement modelling unit. This will help to forecast demand and the understanding of where to position frontline resource during predicted peaks and troughs in activity to support efficient deployment.

The Commissioner will continue to monitor the situation closely and ensure a regular review of staff rosters.

We believe that the way in which demand is predicted needs to be examined and developed to provide better rosters. Especially now that the data is different because of the new response model.

The cycle times of crews and increasing workloads have been included to an extent, however we feel that the data should also include other information other than pure call numbers, an allowance for the day to day occurrences that cannot be planned for such as vehicle breakdowns and prolonged on scene times (such as large incidents even major incidents) to create head room for the management of the fluctuating demands on a daily basis. If hospital waiting is not addressed then that needs to feature in the calculations as well.

At present we feel that rotas are too closely matched to pure demand, which ignores the other things that may occur during the day which affects capacity and the capability to deal with the workload. It would be good, for instance, to be able to stand a crew down from operational duties for meetings with their line manager, be it to carry out PDR or sickness review or team briefings but this is utterly impossible as things stand without affecting response times and patient care. Currently staff are asked to attend such meetings on their days off to avoid affecting resource levels.

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.

In response to the recommendations set out in the McClelland Review, the NHS in Wales continues to bring forward plans to modernise the provision of patient care services.

The first step of this modernisation agenda has involved the transfer of health courier services from WAST to the NHS Shared Services Partnership. The transfer has been successfully completed and the new service started on 1 April 2015. The hard work of everyone involved in the detailed planning for the transfer ensured that there was no disruption in service. Any transfer of non-emergency patient transport from WAST is more complex. We want to make sure any planned changes do not destabilise and put in jeopardy the provision of emergency ambulance services. To this end, the Welsh Government is working closely with the Welsh NHS and WAST on plans for modernising non-emergency patient transport.

A project board is considering a number of options for modernising non-emergency patient transport. As part of this work, I have made it clear that I expect the board to build on the findings and recommendations set out in the Win Griffith’s report including the transfer of best practice that has seen different service models emerge involving partnership working with local authorities to improve efficiencies across the public sector as well as increased provision by community and voluntary sector transport providers.

The NEPTS side of the service does not interfere with EMS, in actual fact it supports it. PCS have been a standalone service for many years but integral to what we do. To fragment the service by taking PCS away would be destabilising for the EMS side as it can be used as surplus capacity during times of extreme need such as Major Incidents and winter pressures.

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.

Lengthy patient handover delays are entirely unacceptable.

The national hospital handover guidance is a clear statement of intent that requires health boards to take responsibility for ensuring the safe handover of patients to hospital teams within 15 minutes. The guidance sets out 10 key actions for health boards and trusts to incorporate in their existing protocols to ensure timely handover. The indications are that delays are beginning to reduce at the majority of emergency departments. The latest information for March indicates there has been a 23% reduction in the numbers of patients waiting over an hour for handover since December 2014.

Our concern is that the data sample that is being looked at was during a period when we would expect improvement. The issues that we have raised above do in our opinion need examining as we head towards this year’s winter pressures. Hospital Waiting seems to be here to stay as no real answers are forthcoming. The capacity for patient throughput in ED’s are always strained therefore more resources and upskilled staff (as mentioned below in C 6) should be made available to WAST. That in itself will not cure the problem, possibly just add to the que outside ED but there are patients not being responded to and it effects staff as many over runs are caused by hospital waiting.

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.

We expect as equitable level of emergency ambulance service provision as possible for all Welsh residents, regardless of where they live with the required levels of frontline cover to support an effective and timely response at all times. We also expect the right clinical resource to be dispatched by WAST’s based on a patient’s need.

The existing eight-minute target can drive perverse behaviour through the dispatch of multiple crews and ambulances in order to achieve the target. Improving the way emergency resources are dispatched to achieve the best possible outcome for patients form part of the service’s clinical modernisation.

A ‘return to footprint’ pilot is underway in the Cwm Taf University Health Board area, which has resulted in an uplift in responsiveness which correlates with the commencement of the trial. The chief ambulance services commissioner has established a quality assurance and improvement panel which reports to EASC and will review and evaluate service improvement initiatives like the trial in Cwm Taf. Membership of the panel includes senior clinical leaders and eminent academics.

Unite feels return to footprint pilot was extremely successful.

What it did show was that the amount of resource available is also critical to cover workload. For this reason we feel that either the rural areas need to be bolstered by increased staffing or in the more populated areas of Wales there is additional resource provided to prevent the whirlpool effect that draws resources out of rural areas into the populated areas to meet increasing demand (as mentioned in responses to conclusions 1 and 3)

By doing this, rural crews could return to their areas to maintain cover.

In addition the further development of Paramedics skills to treat at scene and introducing more Advanced Practice Paramedics (APP) would also reduce the pressure in this situation by becoming a pathway of referral for Paramedic crews and reduce the need conveyance to ED. This along with better pathway availability would both reduce pressure at the door of ED and keep crews in their designated areas.

Possibly each area within WAST should be subject to a safe staffing study/guidance as is done for hospital wards.

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.

I welcome the Committee’s conclusion that more needs to be done collectively to treat patients as close to home as possible, with a focus on a patient’s individual needs to avoid unnecessary conveyance by emergency ambulance to hospital. We have published our national plan for a primary care service for Wales to help drive this.

Underpinned by the principles of prudent healthcare and those featured in the primary care plan, the five-stage ambulance patient care pathway in the quality and delivery framework describes EASC’s expectations for how the ambulance service should provide services to Welsh residents. WAST is expected to meet a series of core requirements, quality measures and clinical indicators described under each of the five stages.

The five-step ambulance patient care pathway clearly marks out WAST’s emergency ambulance service as a clinical service within the wider integrated Welsh healthcare system, and forms part of a multiagency, collaborative approach between health boards and WAST to develop high-performing pre-hospital clinical services. It is intended to ensure patients receive the right care, at the right time from the right clinician to achieve the optimum outcome for every patient.

Significant work has been undertaken as part of the clinical modernisation of emergency ambulance services to improve assessment of patients in the community through the development of a number of initiatives and tools. Emergency department consultants and paramedics triage calls that may be better dealt with closer to home. Alongside this the introduction of the Manchester Triage System to clinical contact centres to provide enhanced clinical assessment of patients. WAST has also implemented the Paramedic Pathfinder tool. This allows the use of a range of safe, consistent and clinically safe, triage and evidence-based processes, which enable paramedics to conduct accurate face-to-face assessment of individual patient's care needs, when they arrive on scene, allowing them to refer to other healthcare settings in the community where appropriate.

Alternative care pathways for patients with resolved epilepsy resolved hypoglycaemia and for patients who have fallen are now supported by WAST in all health board areas with several thousand patients being safely referred to an appropriate healthcare setting other than hospital. These and similar initiatives has resulted in WAST non-conveyance rates which are now among the highest in the UK, conserving precious emergency care capacity to respond to patients who have a clinical need for a timely response and relieving pressure on Emergency Departments.

We totally agree with this approach, however there needs to a dramatic increase in the numbers of staff qualified to the appropriate level to action the clinical model. This problem is not unique to Wales but we can lead the way by allocating the appropriate resources to the training of new staff, the upskilling of present staff to ensure the appropriate response is given to those requesting help from the service.

Closing statement

We are most appreciative for this chance to comment on these issues, issues which are very complex in nature. We are fully prepared to support WAST in moving forward, we believe we are moving in the correct direction but the pace, in areas where we think are important to our membership, is slow which makes it difficult for us to bring our membership with us, years of disengagement have taken their toll on engagement.

The Paramedic profession is very young profession, when compared to Nursing for instance, and has huge potential to improve outcomes and benefit patients both in the Acute/ Critical care arena and the management of chronic conditions in the community. To do this we need to move forward with the wider NHS framework that Paramedics work within so that the profession can realise its potentials. Paramedics and colleagues do not want to be stuck outside hospitals for huge chunks of their shifts, it is both tiring and demoralising and is possibly the priority in all of this; numbers and skill levels count for very little if you cannot get them to the patient.