Memorandum by East Anglian Ambulance NHS
Trust (GP27)
INTRODUCTION
East Anglian Ambulance NHS Trust is England's
most rural ambulance service, serving a population of about 2.2
million people, covering 5,000 square miles within Cambridgeshire,
Norfolk and Suffolk.
The Trust operates a fleet of more than 100
front line ambulances, of which at least 65 are in operational
use at peak times and around fifty single and community paramedic
response units. Our community paramedics serve mainly highly rural
market towns and two deprived urban area populations. These paramedics
fulfill an emergency response role but work in general practices
alongside and with the primary health care teams. We also have
recruited over 300 community lay volunteers and organised them
in partnership with the voluntary aid societies, RAF stations
and others into first response defibrillator schemes to improve
equity of access in rural and coastal locations to life saving
care.
Last year we responded to over 150,000 emergencies
and received over 188,000 emergency calls, representing a 12%
and 20% increase respectively on 999 activity from the previous
year—10% annual 999 response increases having now become
the norm.
We have just implemented a NHS Direct—linked
nurse triage and advice service in the 999 control room for 999
callers with non serious problems. We also have more than 100
Patient Transport Service ambulances undertaking over 700,000
patient journeys a year conveying patients to and from hospital
appointments. Our volunteer ambulance car service drivers travel
millions of miles per year
We deploy and provide air paramedics for the
East Anglian Air Ambulance, which is paid for by charitable donations.
The Trust also runs a round-the-clock message/call
handling service for out of hours called Medicom. Medicom underpins
the current six GP co-operatives working in Norfolk by providing
call handling, telecommunications, cars and drivers. For over
a year the Trust has also worked closely with one particular GP
co-operative and has provided a special primary care trained paramedic,
in the form of a paramedic buddy scheme, to work within the GP
out of hours service.
This collaborative and integrated approach by
the trust for its provision of emergency care in a very rural
environment was influential in our being considered favourably
when we proposed and won the tender to provide the GP out of hours
services for the total population of Norfolk—806,000 patients—following
the release of invitation and service specification from the six
Norfolk PCTs. This means that the current systems that all operate
independently will be merged under the management and leadership
of East Anglian Ambulance NHS Trust. The new service commenced
on 1 June 2004 for Great Yarmouth and is due to commence on 1
July 2004 for the rest of the county.
The new service called "Anglian Medical
Care" will immediately bring together the current GP out
of hours systems operationally with ambulances services and provide
early opportunities to integrate other services such as nurse
practitioners, district nursing, social services and mental health.
East Anglian Ambulance NHS Trust is one of a
few national pilot sites training paramedics and nurses into Emergency
Care Practitioners. The intensive five month training course that
they undertake aims to develop individuals with the requisite
skills in Primary care, out of hours provision, single person
ambulance response, and gives them extended knowledge of patient
examination and assessment techniques. They can also provide medication
for patients using patient group directives.
These professionals will underpin the service
and help promote a team concept for the provision of unscheduled
care. As a result of the extremely short lead-in time for this
new service, there are a very limited number of trained alternative
health professionals to integrate into the new out of hours service
to reduce the burden on GPs, and fewer still anxious to work solely
at night and weekends. In part, as a result of this and the need
to ensure patient safety and confidence, it has been accepted
that the new service will initially be GP dominant reducing over
a period of about three years, once other health professionals
are trained, developed and integrated. But the service will always
still have GPs present to ensure safety and professional support
to other health care professionals.
GENERAL READINESS
OF PCTS
The six Norfolk PCTs have been imaginative enough
to collaborate in commissioning out of hours services. This has
allowed economies of scale, co-terminosity with other health and
social care providers and eradicated many areas of duplication
across PCT boundaries. They collectively released a detailed service
specification and invited prospective providers to put forward
proposals.
Subsequently, all Norfolk, Suffolk & Cambridgeshire
PCTs undertook an assessment of readiness by the Strategic Health
Authority which gave the Norfolk scheme a very positive response[1]
The Workforce Development Confederation is currently undertaking
training needs assessment for future workforce requirements in
out of hours services. Both of these exercises will demonstrate
the general readiness of the PCTs within Norfolk, Suffolk and
Cambridgeshire and help in workforce development in the future.
The SHA-wide Emergency Care Network has now taken responsibility
for coordinating and working with PCTs and providers to develop
these early out of hours schemes into more integrated unscheduled
care services.
THE ROLE
OF GP CO
-OPERATIVES
The role of the GP co-operative has changed
due to the shift of responsibility to PCTs. With most GPs wanting
to enjoy their opt-out status, some GP co-operatives have become
unviable. Some GP co-operatives are forming mutual companies and
taking the opportunity to maintain their provider status in a
new way. Within Norfolk, all six GP co-operatives collectively
agreed to dissolve and worked with East Anglian Ambulance NHS
Trust to amalgamate the current systems into the newly formed
service called Anglian Medical Care. The service proposal that
was put forward to the six PCTs was supported by all six GP co-operatives,
the acute trusts and the Local Medical Committee (LMC). Each of
the GP co-operatives was involved from the beginning and had input
in the planning and the submission of the proposal. The proposal
was submitted to the PCTs with a supporting letter signed by all
GP co-operative Medical Directors and the LMC.
THE ROLE
OF NHS DIRECT
(NHSD)
Department of Health Guidance[2]
defines a model of out of hours care with NHS Direct at the centre.
In Norfolk we have been unable to implement the requirements of
the guidance due to insufficient capacity and growth within NHS
Direct. This has been incredibly frustrating for all parties concerned
as much willingness has been shown locally by NHSD but they have
inadequate capacity to take on this busy additional service. As
an interim measure we proposed and developed a "press button
1" facility, which allowed the caller when calling the out
of hours call centre to have the choice to press button 1 if they
wished to speak to a NHS Direct nurse for advice, or hold for
the GP out of hours services. This interim system, the technicalities
of which have been funded and installed, has remained unimplemented
due to insufficient capacity. At present the Norfolk system has
been Technically Linked[3]
since November 2003. The role of NHS Direct is clearly defined
within the guidance as an integrated holistic service but will
clearly not be up to capacity until 2006. By this time a high
quality alternative solution will have to be in place and this
is unlikely to be dismantled if performing well with good levels
of user satisfaction.
POTENTIAL IMPACT
ON OTHER
NHS SERVICES
The potential impact on other services could
be overwhelming, and make these services unsustainable, performance—wise,
if the service delivered during out of hours is poor. That's why,
in Norfolk, East Anglian Ambulance NHS Trust took the opportunity
to protect its 999 call volume and immediately integrate ambulance
services with out of hours provision. Other areas of serious concern
are A&E and daytime primary care and we are working to protect
these by ensuring that the service delivery is of a high standard
during out of hours and meets users' needs.
It is quite possible that there will be high
levels of patient anxiety about any new out of hours arrangements
following on from a long period of high quality out of hours care
previously provided by many GPs locally, and the change to something
different is causing some concern.
Communications with the public and professionals
concerning the new service being offered is paramount to its success
and this has been undertaken with wide media coverage as well
as consultation with newly formed patient and public involvement
forums and overview and scrutiny committees. We have found in
Norfolk that a better understanding of the service that is being
delivered has helped to try to alleviate the fears and re-assure
patients and professionals that the service being delivered is
of a high standard.
POTENTIAL FINANCIAL
IMPLICATIONS
The amount of claw-back from the Global Sum[4]
has proven to be insufficient to provide a high quality service
within Norfolk. A financial gap exists despite innovative working
and immediate introduction of skill mix within the new service.
The quality standards requirements[5]
for out of hours providers is hard to maintain in a very large
rural area with long journey times and a dispersed population.
Sufficient workforce must be available to cover the geographic
area and ensure that patients receive high quality care within
the timescales set out by the standards.
There is also a feeling amongst many GPs that
the GP workforce has subsidized the NHS and now wants appropriate
(higher) rewards financially for their expertise in continuing
to work within out of hours. The decision to eradicate 24 hours
responsibility from GPs is proving to be a costly one, especially
when this was combined with withdrawal of access to GPs for Saturday
morning surgeries at the same time. The longer term sustainability
of the local GP workforce who are engaged remains a significant
unknown, suitable alternative back up provision is required for
longer term service provision. But the development of a comprehensive
alternative health care professional workforce will take some
years to achieve and will in itself be neither cheap nor easy
to sustain in working anti-social hours patterns.
POTENTIAL IMPLICATIONS
FOR QUALITY
There are potential implications for the quality
of the service if the local GP workforce chooses to exploit their
opt-out rights. Alternative health professionals are required
to maintain a service and there are insufficient trained personnel
available to replace the GPs or change the skill mix to the levels
required. Although the new service has plans to train and develop
these new skills, it will take time and resources. If the quality
of the out of hours service is poor, the impact could be huge.
Within Norfolk the integration with the ambulance service allows
an early opportunity to explore new ways of working and responding
as a team approach. By amalgamating the seven different providers
into one allows the opportunity to standardize all procedures,
protocols and management support. Sudden changes in patient flow
could however impact severely on 999 and A&E performance targets
and manageability of workload.
SKILL-MIX
WITH OUT
OF HOURS
SERVICES
Skill-mix developments within out of hours services
will be crucial to the continued success of high quality service
delivery. Within Norfolk for 18 months we have integrated a paramedic
within the out of hours service with huge success. The new Emergency
Care Practitioners and nurse practitioners will also be a key
part of the new service delivery.
ARRANGEMENTS FOR
MONITORING
Robust arrangements for monitoring the out of
hours service are required. This process can be aided by the computer
systems available. Within Norfolk the Knight Owl(tm) Computer
system is used and provides statistical information that meets
the needs of the accreditation requirements.
IMPLICATIONS FOR
URBAN AND
RURAL POPULATIONS
As mentioned above, providing a high quality
service to a very rural population can prove difficult.
18 June 2004
1 Norfolk, Suffolk, Cambridgeshire Strategic Health
Authority, March 2004. Back
2
Raising Standards for Patients, New Partnerships in Out of Hours
Care, Department of Health, October 2000. Back
3
Phase 1 Technical Links Programme, Department of Health, July
2003. Back
4
Investing in General Practice, The New General Medical Services
Contract, Department of Health, February 2004. Back
5
Accrediting Providers for Out of Hours Care-A System for Improving
Patient Care and Assuring Quality, Department of Health July 2002. Back
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