The Welsh NHS Confederation response to the Health and Social Care Committee inquiry into the performance of the ambulance services.

Contact:

Nesta Lloyd – Jones, Policy and Public Affairs Officer, the Welsh NHS Confederation.

Tel:  XXXXX XXXXXX

Date created:

6 November 2015

Introduction

1.      The Welsh NHS Confederation, on behalf of its members, welcomes the opportunity to respond to the follow-up inquiry into the performance of ambulance services in Wales. Our response will highlight the progress that has been made by Local Health Boards across Wales and the Welsh Ambulance Services NHS Trust (WAST) to bring about improvements in the eight key areas identified during the initial inquiry conducted by the Health and Social Care Committee in March 2015. 

 

2.      By representing the seven Health Boards and three NHS Trusts in Wales, the Welsh NHS Confederation brings together the full range of organisations that make up the modern NHS in Wales. Our aim is to reflect the different perspectives as well as the common views of the organisations we represent.

 

3.      The Welsh NHS Confederation supports our members to improve health and well-being by working with them to deliver high standards of care for patients and best value for taxpayers’ money. We act as a driving force for positive change through strong representation and our policy, influencing and engagement work. Members’ involvement underpins all our various activities and we are pleased to have all Local Health Boards and NHS Trusts in Wales as our members.

 

4.      The Welsh NHS Confederation and its members are committed to working with the Welsh Government and its partners to ensure there is a strong NHS which delivers high quality services to the people of Wales.

 

 

Summary

5.      The role of WAST is to provide high quality pre-hospital and emergency care to the people of Wales. The Service is focused on delivering a clinically-led model of care, with a remit which extends beyond the traditional “transport” model of services to one which is firmly rooted in the overall unscheduled care system in Wales.

 

6.      As highlighted previously, in considering WAST current performance it is important to put it into the context of the overall unscheduled care system and the changing societal, demographic and financial landscape in which the WAST is operating. The issues that we see with ambulance performance are not just about what the ambulance service does. There is pressure on the whole unscheduled care system which has sometimes led to handover delays at emergency units. Health Boards take responsibility for the whole of the unscheduled care pathway because they are able to determine, as integrated Health Boards, what happens at the front end of the service, including in primary and community settings, through to the flow through the hospital, which impacts on the numbers of ambulances waiting outside Accident and Emergency and the ability to hand over as quickly as is needed.

 

7.      Through the National Collaborative Commissioning Quality and Delivery Framework, WAST is working closely with Health Board colleagues to address the issues discussed by the Health and Social Care Committee in its initial inquiry in March 2015. As our response will highlight a number of the conclusions made by the Committee have been actioned by Health Boards and WAST.

 

 

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.

8.      Since the initial inquiry, WAST and Health Boards have worked closely together to improve emergency ambulance response times. Overall ambulance performance has improved month on month over the course of 2015.

 

9.      The revised ambulance clinical model pilot began in October 2015. The pilot model measures the speed and quality of responses to life threatening calls and the quality of care for less serious conditions. This pilot is a UK first and sets the highest level of ambition for ambulance services in Wales as well as underpinning the need for ambulance services to be an integrated part of wider NHS services.

 

10.  Across Wales many new processes and initiatives have been put in place. The commissioning process for ambulance services in Wales has matured since the Committee’s initial inquiry into ambulance services. All seven Health Boards are engaged in this collaborative process via the Emergency Ambulance Services Committee (EASC) and its supporting sub committees.

 

11.  There are local service delivery initiatives in each Health Board area. Service improvement ideas are considered via the Quality Assurance Improvement Panel, or QAIP. This subcommittee of EASC has approved several schemes for pan Wales roll out. These are:

        i.            Mental Health Crisis pathway;

      ii.            Paramedic Pathfinder decision support tool;

    iii.            Improved arrangements for receiving and co-ordinating Healthcare Professional Calls;

     iv.            National co-ordination of frequent 999 caller management; and

       v.            Within the Cwm Taf University Health Board the “explorer” project has examined the effects of ring-fencing ambulance resources in their home Health Board area.

 

12.  The new initiatives across Local Health Boards are highlighted below:

 

13.  In Hywel Dda University Health Board (UHB) the Unscheduled Care Board, and its terms of reference, are being revised to ensure all acute, community, social services and WAST partners review pathway performance. This will be chaired by a Board Director.

 

14.  In Aneurin Bevan UHB fortnightly meetings are held between the Chief Operating Officer, General Manager responsible for emergency services and the Ambulance Management Team to review performance and explore potential improvement opportunities. A comprehensive action plan has been developed to address a number of issues that impact on ambulance performance.

 

15.  Cardiff & Vale UHB has worked closely with WAST through its regular meetings with the Ambulance Commissioner and fortnightly local operational meetings. As part of this process the UHB has run local planning sessions in preparation for the introduction of the revised clinical model for WAST. The services have been aligned to support the new outcomes-based model and the Health Board continues to review processes to allow it to embed and succeed. Clinicians within the Health Board have been fully engaged in this process. 

 

16.  A range of initiatives have been taken forward in Abertawe Bro Morgannwg UHB. These include:

        i.            A telehealth pilot is in place between WAST, 15 care homes and the GP out of hours service to provide additional support to care home staff to maintain residents within the care home, with the aim of reducing conveyances to hospital. This went live in April 2015 and there has been positive feedback from users of telehealth.

      ii.            A new pathway for mental health patients is being piloted in the Swansea/Neath Port Talbot localities from the 30th November 2015. This will ensure the appropriate conveyance of patients and the appropriate access to care.

    iii.            There are advice lines available for paramedic crews to speak to consultants to support clinical decision making. 

     iv.            Introduction of Paramedic Pathfinder. All WAST staff within ABMU Health Board have now been trained, with the exception of those on long term sick leave.

       v.            The development and introduction of structured directory of operating procedures within ABMU Health Board from July 2015 for WAST crews to ensure consistency of approach to conveyances to the appropriate health care environment. This is also now being extended to incorporate standard operating procedures for Prince Philip hospital to support decision making of ambulance personnel for patients on the hospital borders.

     vi.            Ensuring WAST clinical team leaders are involved with the ambulatory care work being progressed on all hospital sites within the Health Board.

   vii.            The planned introduction on the 30th November 2015 of a pilot to implement a dedicated ring-fenced urgent care service for GP expected patients in the Swansea and Neath Port Talbot areas who require conveyance by an ambulance. This will bring forward the conveyance of these patients to earlier in the day and help to smooth the arrival of patients at hospital. Experience in other Health Boards suggests that this change in the process/pathway supports earlier senior clinical review and investigation of patients, resulting in reduced length of stay, reduced hospital admissions and improved patient experience.

  1. Additional WAST support has been secured to support the review of patients who have been identified as being frequently conveyed by ambulance to hospital from care homes. This work is being progressed jointly between WAST, the Health Board, care homes and GP out of hours service.
  2. WAST staff have been trained to identify patients with long standing neurology conditions, resulting in a better patient experience for this group of patients.
  3. The multi-agency help point plus service (Swansea) to support admission avoidance from the city centre at weekends/bank holidays. The service has been in place since the autumn 2014 and there is evidence that paramedic attendance at Wind Street in Swansea has reduced.
  4. New pathways are being jointly developed between WAST, GP out of hours and the Health Board as part of the move towards the implementation of the 111 service next year.    

 

17.  The Betsi Cadwaladr UHB Unscheduled Care Strategic Board and local Unscheduled Care groups’ terms of reference include acute, community, social service and WAST partners. All groups review unscheduled care performance and explore potential improvement opportunities. A comprehensive action plan has been developed to address a number of issues that impact on ambulance performance.

 

18.  The relationship between Powys Teaching Health Board and WAST is slightly different from other Health Boards in that Powys does not manage any acute care services and has no Accident and Emergency Departments. The Health Board manages 10 Community Hospital facilities, with 176 largely rehabilitation beds, and including four Community Hospital based Minor Injuries Units. The Health Board’s Unscheduled Care Programme has a strategy of:

        i.            Keeping people healthy and living independently in their own homes and communities as much as possible, thus reducing inappropriate demand on more acute healthcare services, and

      ii.            Returning people back to their communities from acute care as quickly as safety allows, thus improving the flow through the healthcare system.

 

19.  The Health Board has been reasonably successful in delivering this, reporting lower than Welsh average A&E attendances, emergency admissions per head of population and length of stay in acute care for emergency admissions and good rates of alternative use to both emergency ambulance and emergency care services.

 

20.  The general level of performance against the traditional A8 target for Powys Health Board has generally been below 60%, however this figure tends to mask the impact of the rurality of the county and the dispersed nature of its population. For example, an analysis undertaken in June 2015 showed that although only 54% of A8 calls were reached within the required time, around 72% of those that were not were actually unreachable within the six minute drive time allowance because of where they lived. In effect this means that the Ambulance Services reached around 80% of those that could be reached within eight minutes.

 

21.  The rurality of Powys, and the fact that there are few large centres of population (Welshpool is the largest town with a population of just under 13,000) means that many Powys residents cannot be reached within eight minutes, irrespective of system performance or resource deployment. This is an important, if subtle nuance to consider when reviewing performance in Powys.

 

22.  For these reasons, amongst others, Powys Teaching Health Board welcomes the revised performance measures and also strongly endorses the recent decision by WAST to develop outcome measures that include survival rates for those transported to hospital by emergency ambulance.

 

23.  In a broader context, and given the issues noted above, it is important to stress that in a county such as Powys, road quality is a hugely important factor and developments such as those that have occurred in the Heads of the Valleys in recent years are warmly welcomed. Access to services via these roads, particularly during periods of adverse weather, is an important factor in ensuring that transportation times to and from acute centres are kept to a minimum. 

 

24.  Powys is fortunate in that most Ambulance Services staff based in Powys are residents of the county and understand the needs and anxieties of the local population. Concern has been expressed that as more specialist services provided by other Health Boards and Trusts move further away from our borders, through the current processes of consolidation and rationalisation, more ambulance time will be spent out of county.

 

25.  A number of specific developments are being implemented or planned, as part of Powys teaching Health Board Unscheduled Care Improvement Action Plan, aimed at both reducing unnecessary demand of unscheduled care services and improving delivery performance, including ambulance service.

 

 

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.

26.  There has been progress towards a whole system approach to unscheduled care across Wales and all Health Boards have been fully engaged with the work of WAST. All seven Health Boards are represented on two key sub committees of the main EASC group:

i.            The Performance Delivery Group is attended by the Chief Operating Officers/Directors of Operations from the seven Health Boards. Within this group, chaired by Chief Ambulance Services Commissioner, Commissioners and WAST considers current performance and advise EASC of a common position. The group will provide appropriate challenge regarding performance and agree corrective actions and escalation.

ii.            The Collaborative Commissioning Group is attended by ambulance commissioning champions from each Health Board. These champions represent primary care, planning, commissioning and community care functions within Health Boards. This group manages, maintains and monitors the implementation and development of the National Collaborative Commissioning: Quality & Delivery Framework. It is chaired by the Chief Ambulance Services Commissioner.

 

27.  At a local tactical level WAST and Health Board managers are engaged. The examples of local work below demonstrate in more detail the outputs of this engagement:

 

28.  In Hywel Dda UHB, WAST are part of the Health Board’s plans for any changes in service. Recently Hywel Dda UHB had to change the borders in order to reduce the medical intake at Withybush hospital and WAST were part of the planning and ongoing review. This can be clearly evidenced from the early engagement with WAST following the changes to women and children’s services, and the commissioning of the dedicated vehicle based at Withybush, and more recently the temporary change to patient flows, due to staffing issues.

 

29.  The collaborative working between WAST and Primary Care within Hywel Dda UHB supports conclusions 2 and 7 within the initial Committee inquiry report. Within Hywel Dda UHB they have worked collaboratively with WAST to develop an Unscheduled Care Team which has now morphed into the Primary Care Support Team. Practices across Wales are facing workforce challenges and in many areas are not able to meet patient demand for appointments/home visits. This could be argued would have a knock on effect  to WAST with a potential increase  for calls due to patients not being seen in a timely way and panic/concern setting in. Through the introduction of  the Advanced Practitioners into one GP practice, patients are being seen by  an appropriate Health Care Professional and 75% of requested home visits are being seen by an Advanced Practitioner in a more timely way after an initial telephone triage with a GP (working in accordance with WAST Call prioritisation e.g. Green 1,2,3). This enables the patients to be seen within their home and reduces their anxiety and need to call for an ambulance.

 

30.  Aneurin Bevan UHBs Senior managers who liaise with WAST participate in national and local joint working to explore and share best practice and interpret this for patients. WAST managers are part of the Health Board’s seasonal planning and local delivery plans in areas that will impact on WAST service. Examples of this are:

                    i.            Members of Seasonal Planning Board;

                  ii.            Members of Stroke Centralisation Board; and

                iii.            Member of Urgent Care Transformation Board.

 

31.  In Cardiff & Vale UHB monthly meetings are held between the Health Board’s Chief Operating Officer and the ambulance commissioner to ensure that planning and operations are aligned. Where there are operational and planned changes that may affect, or improve, ambulance performance these are shared and discussed jointly, through the fortnightly joint operational meetings. Whole system implications of service change are duly considered.

 

32.  In Abertawe Bro Morgannwg UHB monthly Unscheduled Care Delivery Meetings are chaired by the Chief Operating Officer with other members of the Executive Team, the WAST Head of Operations for Abertawe Bro Morgannwg UHB and senior clinical and operational managers. Local site based meetings involve operational colleagues from WAST as needed.

 

33.  Betsi Cadwaladr UHB and WAST senior operational managers meet monthly to jointly plan and implement any changes in service. Recent changes managed in this way are Paramedic Pathfinder and alternative conveyance projects aimed at reducing demand in the Emergency Departments. WAST managers are part of the Health Board’s seasonal planning and local delivery plans in areas that will impact on WAST service. In addition, WAST are a member of any group within the Health Board where they discuss unscheduled care.

 

34.  Powys teaching Health Board has a number of mechanisms for engaging with WAST on an ongoing basis. These include:

        i.            Emergency Ambulance Service Committee: The EASC meetings are attended by the Director of Primary and Community Care, or Deputy, and the Health Board has contributed fully to the development of the Quality and Delivery Framework;

      ii.            Strategic Planning: WAST colleagues are involved in the development of the Health Board’s strategic plan and have contributed to a number of strategic planning workshops;

    iii.            Unscheduled Care Board: WAST colleagues are full and active members of the Unscheduled Care Board, which is responsible for the development and delivery of a joint Seasonal Pressures Plan and an Unscheduled Care Improvement Action Plan;

     iv.            Health Focus Groups: These provide an opportunity for the Health Board to engage with local communities on an ongoing basis. WAST has access to these arrangements via the Locality Teams on an ongoing basis and attend either to address issues of concern in the local community or to brief or inform local communities in relation to Ambulance Service changes;

       v.            Specific Consultations: Where major changes are planned and consultation is required, WAST colleagues are included as appropriate;

     vi.            Locality Management arrangements: Local links are strong between Health Board locality and WAST operational managers and this is reflected in the level of engagement in pathway development across the Health Board.

 

 

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.

35.  In Hywel Dda UHB new rosters have been introduced from 14th September 2015. This will now follow the Local Development Plan process with roster reviews undertaken annually.

 

36.  In Aneurin Bevan UHB the Health Board and WAST’s local joint meeting’s agenda covers the commissioning requirement and a joint action plan includes roster improvements and exploring ring fencing of certain staff and services that will allow protection of the emergency response crews. Examples of this are:

        i.            Ring fencing hospital car service crews to convey health care professional requested admissions to the assessment areas in a timely manner and release the emergence crews to attend the 999 calls; and

      ii.            Joint job description development for ambulance liaison officers to meet both WAST and Health Board needs.

 

37.  In Cardiff and Vale UHB local roster changes for ambulance service staff have been put in place by WAST in recent months.

 

38.  Betsi Cadwaladr UHB and WAST local joint meeting’s agenda covers the commissioning requirement particularly mismatches between staffing and anticipated demand.

 

 

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.

39.  Significant work has been undertaken over the last year with WAST working with a range of statutory and non-statutory partners on developing a business case that sets outs a preferred option for the future provision of Non-Emergency Patient Transport Services (NEPTS) in Wales in the future. In October that business case was approved by the NEPTS Project Board, the Chief Ambulance Services Commissioner and Chief Executives of Health Boards and Trusts across Wales and, as a result, was submitted to Welsh Government.

 

40.  The business case recommends that NEPTS remain managed by WAST but that WAST uses multiple providers to deliver the service.  Specifically, it is proposed that local authorities, community transport providers and third sector organisations are used, in conjunction with WAST, as service providers.

 

41.  The NEPT service will be completely disaggregated from the provision of the emergency ambulance service within WAST, with an entirely separate management structure. Following a full and detailed options appraisal which considered alternative models of delivery, including devolving the service to Health Boards, all stakeholders, including the Chief Executives of all Health Boards, WAST, Velindre NHS Trust and the Renal Clinical Network agreed that the alternatives represented neither value for money nor improved service delivery.

 

42.  A new service specification has been developed by the health community commissioners which includes costing and timeframes for implementation. This new service specification also includes enhanced services for renal, end of life and oncology patients. At the time of writing, WAST and its partners are awaiting approval of the business case from the Welsh Government. In the interim, the information below summarises some of the initiatives that have been undertaken by Health Boards.

 

43.  In Aneurin Bevan UHB the Health Board holds a separate contract with Patient Transport Service to deliver their discharge transport arrangements. Regular meetings occur between bed management and the Patient Transport Service to manage and adjust this contract. The ring fencing of the health care professional admissions described above on page 6 also allows the emergency crews to be available for 999 calls.

 

44.  In Abertawe Bro Morgannwg UHB the following initiatives have been taken forward:

        i.            Taxi initiative: From the early part of this financial year WAST has utilised 89 taxis for the conveyance of appropriate patients to hospitals within ABMU Health Board, and therefore avoided the use of highly skilled ambulance crews. This uptake compares well with other UHB areas. ABMU Health Board are continuing to promote the use of the taxi initiative for any appropriate low acuity calls received;

      ii.            A new pathway has been introduced for pre-hospital blood tests which means that these are now initiated by ambulance personnel, to reduce assessment times upon arrival at hospital. This initiative has also reduced the door to needle time of stroke patients by 30 – 40 minutes;

    iii.            Alternative pathways in place for resolved epilepsy, resolved hypoglycaemia and falls patients, with 538 patients avoiding hospital conveyance as a consequence between April and September 2015;

  1. A review of the access criteria to the Minor Injuries Unit at Neath Port Talbot hospital has recently been undertaken. Consequently the standard operating protocol is being rewritten and will be re-launched to ambulance personnel to maximise and increase the conveyance by ambulance of appropriate patients to this service;
  2. The Acute GP Unit (Singleton) pathfinder pilot has been implemented. The acute GP at Singleton has access to the ambulance stack and works directly with ambulance service attending supported targeted call selection of patients, and visiting these patients in their home setting. The aim is to support the patient at home or access other community support to maintain the patient at home, thereby avoiding the need for conveyance to hospital; and
  3. The close liaison and working between the Health Board and WAST on the implementation of the new clinical response model.   

 

45.  Betsi Cadwaladr UHB holds a separate contract with Patient Transport Service to deliver their discharge transport arrangements. Regular meetings occur between the Health Board and WAST Patient Transport Service to manage and adjust this contract.

 

46.  Following the recommendations of the McClelland Review, Powys teaching Health Board has been strongly represented within the NEPTS Board to identify and consider options for the future of NEPTS in Wales. The work to explore options for disaggregation have now been completed and a comprehensive business case has been drafted. The Board also took the opportunity to appraise other non-full disaggregation options that would allow a sustainable improvement to Emergency Medical Services performance. These have also been detailed within the case. 

 

47.  In Hywel Dda UHB this is ongoing as part NEPTS work stream. In Cardiff & Vale UHB the Health Board will continue to work with WAST in its intention to disaggregate emergency and non-emergency transport services.

 

 

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.

48.  Ambulance handover delays have reduced in 2015 from the levels seen in 2014 but this continues to be an operational challenge in all but one Health Board area. Cwm Taf UHB continues to lead the way in managing ambulance handover. The national ambulance handover guidance issued in 2014 was not universally implemented across the seven Health Board areas.

 

49.  In Hywel Dda UHB a key focus on lost hours is in place which is reviewed daily. Under times of high demand and handover delays, WAST deploy a senior manager alongside the Health Board to ensure ambulance handovers are expedited. The handover policy has been implemented and currently under review.

 

50.  In Aneurin Bevan UHB the urgent care plan is designed to reduce the delays across the patient pathway to prevent exit block from Emergency Department that can lead to ambulance delays. An urgent care transformation board has been set up in the Health Board that addresses the urgent care pathway across all sectors. Examples have been provided previously of a pathway approach to managing patients flow. In addition Aneurin Bevan UHB:

        i.            Ensures early assessment by a senior doctor: Emergency Department consultant or Advanced Clinical Practitioners taking calls directly from GPs and scheduling the unscheduled pathway for appropriate patients into dedicated slots;

      ii.            Makes good use of short stay beds for Emergency Department appropriate patients;

    iii.            Is improving communication with wards (use Vocera person to person calling system); and

     iv.            Ensures use of fast track pathways effectively e.g. fractured hips and stroke.

 

51.  Other local initiatives are the creation of an ambulance liaison post funded by the Health Board to be based at peak times in the Emergency Department and facilitate the handover of patients and release crews. This was initially run as a Plan-Do-Study-Act (PDSA) cycle and significantly reduced handover delays. The Health Board has also introduced the handover policy.

 

52.  In Cardiff & Vale UHB handover delays and hospital lost hours have been placed as one of the highest priorities since December 2014. The Health Board has worked internally to improve its standard operating procedures, and with the Welsh Government Delivery Unit to revise its escalation procedures, particularly focused on minimising ambulance delays. The graph below shows the reduction in monthly ambulance lost hours for Cardiff and Vale UHB in 2015-16 in comparison to previous years. Year to date (April to September), this represents a 62% improvement over the same period last year and a 77% reduction since the highest peak of lost hours in December 2014.

 

 

53.  In Abertawe Bro Morgannwg UHB compliance with national handover guidance has been reviewed with some improvement implemented to improve communication and handover, particularly for Red 1 calls. In addition, the Health Board played a major role in support of the implementation of the Emergency Medical Retrieval Transfer Service (EMRTS) in April 2015. Effective internal escalation is a key component of reducing hours lost through ambulance delays, and now includes risk based use of pre emptive transfers to wards to reduce congestion in Emergency Departments.

 

54.  Betsi Cadwaladr UHB’s key focus on lost hours is in place and is reviewed daily. Under times of high demand and handover delays, WAST deploy a senior manager alongside the Health Board to ensure ambulance handovers are expedited. The Health Board’s unscheduled care improvement plan is designed to reduce the delays across the patient pathway to prevent exit block from Emergency Departments that can lead to ambulance delays. The handover policy is being implemented by the Health Board.

 

55.  As Powys teaching Health Board does not provide Accident and Emergency Services, the Handover Policy issues have a limited direct impact. The Health Board has raised the potential implications of increased travel time to access specialist services further afield as services are rationalised, and it continues to support other Health Boards in their attempts to reduce handover delays at their own facilities.

 

 

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.

56.  The “Explorer” project is a joint initiative between WAST and Cwm Taf UHB. Explorer began in March 2015. The “Explorer” project ring-fences WAST resources based at stations within the UHB area for calls within the UHB area. Explorer was designed to resolve longstanding poor operational performance in the Cwm Taf area and the fact that Cwm Taf resources were often deployed to calls outside of the UHB area and therefore not available for calls in their home area. As part of the “Explorer” project, resourcing in Cwm Taf was bolstered by some private provided additional ambulance crews. Over the course of the project operational performance has improved month on month. WAST and Cwm Taf UHB are currently evaluating the financial and clinical outcomes of the explorer model.

 

57.  In Aneurin Bevan UHB the introduction of a protected response to care for 35 patients enabled a pilot of retaining crews in their footprint area in Cwm Taf UHB. The initial findings were good and the local WAST management team are planning to run a similar system in Aneurin Bevan UHB at the conclusion of some imminent recruitment.

 

58.  Cardiff & Vale UHB has supported the ring fenced ambulance approach taken within neighbouring Health Boards. In particular, within the Cwm Taf UHB area. While the evidence suggests that this has been beneficial for the Cwm Taf UHB area, Cardiff & Vale UHB has been clear that this can only work if it is applied regionally and therefore would recommend that the approach should be implemented across neighbouring Health Boards.

 

59.  In Abertawe Bro Morgannwg UHB recent developments in the role of Morriston Hospital as a regional centre has affected ambulance flows out of neighbouring areas, for example in relation to vascular emergencies.  There are a number of clinical services which pull patients in from surrounding areas to ensure the best outcomes, and this needs to be taken into account in the planning and commissioning of services in the future.

 

60.  Betsi Cadwaladr UHB is actively involved in the development of WAST commissioning through the Emergency Ambulance Services Committee and Collaborative Performance Delivery Group.

 

61.  Powys teaching Health Board supports any action to limit the negative impact of vehicles “pulled away”. The loss of ambulance capability to respond due to the effect of vehicles being off the patch is a concern. The Health Board is conscious of the fact that, as they border most other Health Boards in Wales and a number of Trusts in England, they are both losers and gainers in this respect, with vehicles from other areas also providing additional capacity to Powys when needed.

 

62.  In Hywel Dda UHB this is currently under review as part of the integrated performance review process.

 

 

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.

63.  Through the collaborative commissioning process monthly data capture on 23 Ambulance Quality Indicators is recoded. A key metric is the referral of 999 patients to different parts of NHS Wales. Referral rates remain largely static across Wales with around 61% of 999 callers being conveyed to an emergency department.

 

64.  As shown below there are a number of local initiatives which are being developed.  As described earlier in this submission, the National Collaborative Commissioning Quality and Delivery Framework has selected several work streams for roll out on a pan Wales basis. 

 

65.  In Hywel Dda UHB, through the collaboration with WAST, patients are seen in the community either at home or within General Practice. The role of the Advanced Paramedic Practitioner (APs) is aimed at visiting the lower acuity calls and there is recognition that there was overlap between these visits and those made by GPs. By working within General Practice, the Advance Practitioners are able to visit those patients before they become an emergency call and are treated where they feel most comfortable, usually at home as opposed to a hospital setting.

 

66.  Working collaboratively with WAST from a primary care perspective has enabled the following benefits:

        i.            Increased capacity for GPs in the practice as the APs undertake over 75% of the home visits;

      ii.            Patients arriving at the practice are triaged and either signposted or treated by the AP that day rather than being turned away;

    iii.            Patients are given an appointment with an appropriate healthcare professional  thereby supporting the diversification of the workforce;

     iv.            Professionals building better working relationships where there have previously been tensions between GPs and WAST staff;

       v.            Rapid activation of the APs skills in a way not currently possible within WAST;

     vi.            Positive feedback from patients; and

   vii.            Positive feedback and engagement with the Community Health Council.

 

67.  Community pathways are in place to avoid hospital attendance and admission. Further work is underway to expand these. The current pathways are being utilised; Advance Practitioners are working across organisational boundaries to support appropriate care within both primary and secondary care.

 

68.  Aneurin Bevan UHB and WAST have collaborated on a number of initiatives that will allow crews to be released rapidly from their Emergency Departments and assessment areas to prevent the conveyance of patients unnecessarily through redirecting them into a more appropriate pathway. Examples of these include:

        i.            Physicians’ response unit where an Emergency Department consultant is deployed with a paramedic to patients that can potentially be treated at the scene and not conveyed;

      ii.            Joint pathway for non-injured falls patients that allows ambulance staff to hand over to another professional who can meet their needs at home;

    iii.            An Ambulance Liaison Officer at the acute Emergency Departments to facilitate handover and release of crews;

     iv.            Working with nursing homes to encourage end of life anticipatory care plans;

       v.            Identify, and care plan for, ‘frequent flyers’ which often impact on a number of services;

     vi.            Paramedic practitioners minor procedure training (wound glue);

   vii.            Alcohol treatment centre; and

 viii.            Internal diverts between departments in escalation.

 

69.  Cardiff & Vale UHB supports the development of ‘upstream’ alternatives to conveyance to hospital. It has been proactive in the development of alternative pathways, for example, the development of a direct assess mental health pathway. The Mental Health Crisis Pathway was initially piloted in the Cardiff and Vale UHB area. This pathway allows ambulance crews to refer patients known to the crisis team directly to a Mental Health professional rather than conveying them to the emergency department. This pilot has been running for one year. 164 patients were referred to the pathway. 132 of these cases resulted in a management plan which did not require the patient to travel to Emergency Departments. Patients were referred to community based care or taken directly to a Mental Health unit. This is a prudent and clinically effective pathway making good use of an existing service.  This pathway has been selected for roll out on a pan-Wales basis. A community communications hub approach has been successfully implemented in the Vale Local Authority area and is being replicated through a single contact point in Cardiff Local Authority.

 

70.  Betsi Cadwaladr UHB and WAST have collaborated on a number of initiatives that will allow crews to be released rapidly from their Emergency Departments and assessment areas. This will prevent the conveyance of patients unnecessarily by redirecting them into a more appropriate pathway. Some of the initiatives include:

        i.            The Paramedic Pathfinder has been rolled out to ensure patients are treated in the most appropriate setting through formal pathways;

      ii.            Minor Injury Units are utilised by WAST for appropriate patients;

    iii.            Treatment Escalation plans for palliative care patients in care homes are being piloted and will be rolled out across North Wales once evaluated;

     iv.            Through the collaboration with WAST, patients are being seen in the community either at home or within General Practice. The role of the Advanced Paramedic Practitioner has been introduced to provide visits for the lower acuity calls as an alternative to admission wherever possible.

       v.            An Ambulance Liaison Officer at the acute Emergency Departments to facilitate handover and release of crews; and

     vi.            Community pathways are in place to avoid hospital attendance and admission. Further work is underway to expand these.

 

71.  In Powys teaching Health Board their approach to unscheduled care is based on ensuring that people receive the level of care appropriate for their needs and the Unscheduled Care Improvement Plan contains a number of improvement actions that have been mapped to the WAST “5 Step Pathway”.

 

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.

72.  Through the Integrated Medium Term Planning process Health Board plans are increasingly including developments that link WAST and Health Board activities to design services based on need.

 

73.  In Aneurin Bevan UHB demand and capacity planning has been used to introduce a more bespoke response to ambulance demand. A Plan-Do-Study-Act (PDSA) cycle was run last winter to provide an alternative response to 999 crews to non-injured falls patients. The PDSA failed to reach the expected volume of patients to make it a cost effective approach. A review of current data has indicated that this service may be more appropriately targeted at two areas of the borough which will reduce travel time, increase potential to attend more calls and prevent inappropriate conveyance. A high percentage of emergency calls in Aneurin Bevan are related to falls and this adjusted PDSA will be run in the next few months. The areas chosen have the higher demand and also are currently the lower performing areas within the Health Board.

 

74.  Cardiff & Vale UHB is acutely aware of the need for medium and longer term planning aligned to predicted demand. The changing demographic and expected population growth in Cardiff features predominantly in such plans. This includes work undertaken on the geography and impact of anticipated housing and estates growth, and the need for local community infrastructure in terms of health, wellbeing and access to primary and social care services.

 

75.  Abertawe Bro Morgannwg UHB is actively involved in the development of WAST commissioning through the Emergency Ambulance Services Committee and Collaborative Performance Delivery Group and is also planning to be the pathfinder site for 111 in 2016 which will be a lever to remodel the whole unscheduled care system and consequent patient flows.

 

76.  Betsi Cadwaladr UHB works closely with WAST colleagues on commissioning and planning of service change when they anticipate changes in terms of demand and demography.

 

77.  In Powys teaching Health Board WAST colleagues have been involved in the Health Board’s strategic planning activities including demand and capacity modelling. This involvement will continue in both a planning context and as changes to service models start to be delivered, in line with the engagement arrangements noted in Conclusion 2 above.

 

 

 

 

Conclusion

78.  Health Boards are commissioners of primary, community, secondary and tertiary care services. As providers, their own services are firmly placed in the primary and community setting, reflecting both planned and urgent primary and community care service delivery. The Health Board’s relationship with the WAST, as its primary provider of out of hospital emergency care, is a crucial one.

 

79.  Health Boards are committed to continuing to work closely with WAST to ensure that the services provided to their residents are of the highest quality, appropriate to need and equitably applied, and also that the systems and processes in place within Health Boards positively support improved Ambulance Service performance.  

 

80.  The National Collaborative Commissioning Quality and Delivery Framework and 5 step Ambulance Service Care Pathway is an innovative model which allows Health Boards and the ambulance service to work together to deliver joined up services.