Knight Review of Fire and Rescue Services

Written evidence submitted by the Association of Ambulance Chief Executives (FRR 18)

 Association of Ambulance Chief Executives (AACE)

The Association of Ambulance Chief Executives (AACE) provides ambulance services with a central organisation that supports, coordinates and implements nationally agreed policy. It also provides the general public and other stakeholders with a central resource of information about NHS ambulance services. read more…

The primary focus of the AACE is the ongoing development of the English ambulance service and the improvement of patient care.

Background

This statement has been prepared by the Association of Ambulance Chief Executives (AACE) to assist the Select Committee following the report by Sir Ken Knight into Efficiency in Fire and Rescue Services (FRS’s).

AACE recognises that FRS’s undertake a very wide range of specialist roles and that call reductions gained from extensive prevention work and subsequent decline in deaths and injuries from fires is enviable. It is also recognised that other agencies, the ambulance service included would benefit from even closer working with FRS’s in some areas. However AACE is of the view that the true benefits realisation would only be possible once a detailed piece of robust independent research had been completed across all organisations involved. This would need to be undertaken, by an independent body to ascertain where true efficiency gains could be identified and implemented with a strong evidence base.

Existing Joint Working Arrangements

There are numerous examples of joint working between ambulance services and their police fire and rescue counterpart organisations across England. The primary motivations for joint working have historically been the improvement of care for service-users and joined-up, responsive service provision. In some areas of joint working cost reduction is not a motivation nor is it ever likely to be achieved; when co-responding, for example, a fire and rescue or police service response will never actually negate the requirement for an ambulance service response thus savings will not be made but the assurance of a timely response will be enhanced. Where appropriate, cost savings and improved efficiency have been sought and achieved; more work needs to be done, however, to quantify where financial benefit has been realised.

Furthermore, despite the shared arena within which police, fire and rescue and ambulance services sometimes operate; the differences between the organisations and service they deliver also needs to be recognised. The English ambulance service has a very lean management structure and its evolution into its current ten-service structure has been in part driven by increasing efficiencies and gaining cost savings, which have been realised. Demand for Ambulance services increase on an annual basis and they are delivered in the context of an ever-reducing financial envelope. New opportunities for cost savings and reduced spend are sought on an on-going basis to maximise returns for patients, however, the differing contexts within which the blue light services operate must be considered when determining where long-term gains and savings can most effectively be made.

Ambulance Trusts already work very closely with Fire and Rescue Services and Police Services to a lesser or greater degree around the country e.g.

· Joint training and exercising

· Shared use of Control room buildings

· Shared use of Fire Stations

· Defibrillators placed on Fire appliances

· Co-responding by Fire Service Personnel to 999 calls to ambulance services, particularly in rural communities

Set out at the end of this submission are some examples from around England of work that has either already been implemented, or is planned.

Financial Position

The Ambulance Service has embraced rationalisation and has reduced the numbers of Ambulance Trusts from 31 (2005) to 10 (2013). This rationalisation has facilitated considerable cost savings and efficiencies across a number of areas including management costs, support service costs and procurement. Management costs in particular have been significantly reduced overall and a whole range of other operating efficiencies have been achieved across England.

Unpicking these established arrangements and re-introducing them across 45 Fire and Rescue organisations would inevitably increase costs.

Overall costs for the English Fire and Rescue Services are in the region of £2.3 billion annually compared to £1.6 billion for the Ambulance Sector.

Response rates and efficiency

The ambulance service deals with approximately 25,000 calls a day at peak, whilst the fire and rescue service handles circa 1,700 calls (2013).

Speed of response is a significant indicator for the Ambulance Service as are clinical quality indicators, which are benchmarked nationally and include: outcome from acute ST-elevation myocardial infarction; outcome from cardiac arrest; outcome following stroke; proportion of calls closed with telephone advice or managed without transport to A&E (where clinically appropriate). Response times alone provide a one-dimensional view of a multi-dimensional service.

In terms of efficiency, the ambulance service’s utilisation rate is running at circa 60%. This means that for 60% of the available hours worked by an ambulance professional they are actively engaged on dealing with emergency calls.

On a national level, ambulance and fire and rescue services’ workload can be compared as follows for 2011/12:-

· UK ambulance services received 8,490,000 emergency calls

· UK fire and rescue services received 584,500 emergency calls

· Total ambulance service calls increased by 5.1% (compared to 2010-11)

· Total fire and rescue calls decreased by 7% (compared to 2010-11)

The increase in calls for ambulance services between 2010/11 and 2011/12 equates to 410,000, which ambulance services have absorbed year on year.

Clinical context

The Ambulance Service is both an emergency service and a fundamental NHS service provider. The patient’s NHS journey commonly starts with a 999 call answered by Ambulance Service Emergency Medical Dispatcher (EMD) operating a sophisticated telephone triage system which determines the medical priority for the patient and assigns an appropriate response within an appropriate time frame. In many cases this is accompanied by on-going telephone advice on how to maintain and stabilise the patient’s condition prior to the arrival of the ambulance response. Furthermore, up to one third of the NHS 111 contracts in England are or are likely to be held by the Ambulance Service.

NHS professionals are embedded within this system with paramedics and nurses working alongside each other within ambulance control rooms advising patients. Telemedicine systems are often in place putting NHS paramedics in touch with NHS emergency consultants to enable more complex procedures to be carried out in the field. The NHS is embedded within local communities with networks of ambulance community first responders reacting to emergencies backed up by paramedics and emergency medical technicians. Professional ambulance clinicians are able to ensure the best possible treatment and advice is given to patients, ensuring continuity of care is started and facilitated throughout the NHS system. Fracturing this system by separating out components of it to different providers would undoubtedly lead to a worse service for patients as well as undermine the flexibility of the current system.

Ambulance services feel strongly that patients would prefer to have their healthcare delivered by an organisation that sits within the NHS as opposed to outside it. Ambulance service public satisfaction surveys have always shown that circa 95% of the public are very satisfied with ambulance service provision. The totality and quality of the patient care provided obviously has a direct impact upon both satisfaction and patient outcomes. The ambulance sector has introduced a suite of Ambulance Quality Indicators designed to measure patient outcomes and not just response times. These are underpinned by complex and well established medical oversight and governance processes.

Ambulance services are responsible for managing the demands placed upon them by the 999 system, general practitioner (GP) admissions and inter-hospital transfers together with a Patient Transport Service (PTS) component in most Trusts. Relationships with clinical commissioning groups, acute trusts and primary care providers are key to their safe and effective delivery and these relationships are well developed within the ambulance sector. Ambulance services engage extensively both locally and nationally with the NHS and would seek to continue this so to ensure no major risks are presented to the rest of the NHS.

As part of this role, ambulance services are required to forewarn the wider NHS of impacts which will affect normal service delivery up to and including the declaration of a major incident. This is underpinned by considerable legislative and governance processes. As an NHS funded provider of care, ambulance services are required under the Health and Social Care Bill to be registered as a provider of health care with the Care Quality Commission (CQC), which is underpinned by considerable compliance requirements and very robust governance arrangements. This in turn demands that high level clinical oversight is maintained and Ambulance Trust Boards must have a Medical Director and a Nursing Director to lead on these issues.

In addition to the complexities of the healthcare system and the ambulance service’s fundamental role within it (as outlined above), there has been considerable evolution of the role played by ambulance services over the past few years. Road traffic collisions and life threatening emergency incidents now represent a very small proportion of the ambulance service’s workload. Closer working with the Fire and Rescue Service would therefore not be relevant for the majority of calls. The focus is increasingly on urgent care and the development of more appropriate patient pathways, a focus which can only be achieved through close collaboration and partnership-working with other elements of the NHS. Any attempt to move ambulance services away from the NHS would have a negative impact on these developments and in all likelihood would lead to more patients being taken to already overstretched Emergency Departments.

The recent introduction of a national ambulance Hazardous Area Response Team (HART) capability across England has been an excellent example of close working and cooperation between the Fire and Rescue services and Ambulance services. It has brought the ability for ambulance professionals to bring definitive care to patients inside contaminated and dangerous areas and has saved many lives since its introduction.

HART train in collaboration with fire and rescue services , as they do with other emergency services and agencies, for some parts of their educ ation, and in the main this training has been led by the ambulance service. It is vital to recognise that being part of the NHS facilitates joint training and exercising whilst encouraging cross-fertilisation of ideas by different NHS clinicians meeting and sharing best practice. Should the ambulance service no longer sit within the NHS, maintenance of these clinicians’ skills would be at risk as exposure/access to the wider range of medical disciplines, organisations and individuals would lessen.

Complexity and culture

Only circa 2.6% of all 999 calls to the ambulance service are to RTCs and fires, of those only about a third of RTC’s attended by the ambulance service require the assistance of the Fire Service. Furthermore, less than 10% of emergency calls to the Ambulance Service also require the attendance of the police. In other words, approximately 90% of emergency calls to the Ambulance Service are dealt with by the Ambulance Service without the attendance of Police or Fire Services.

The ambulance sector has a proven ability to work cohesively across England providing a consistent level of service delivery and patient care. Established systems are in place which allows Chief Executive Officers (CEOs) and Chairs to work closely with ten national director groups to help shape national strategy and implement policy in a consistent manner. Mutual aid arrangements are very well developed allowing a national ambulance sector response to a crisis or to large national events like the 2012 Olympic and Paralympic Games.

Ambulance Trusts have embraced new technology and modernised working practices to deliver highly efficient, flexible response regimes based on sophisticated analysis of demand patterns. In doing so they have managed to improve response times and patient outcomes, absorb significant increases in workload year on year, and also deliver challenging cost improvement programmes. This has resulted in lean efficient organisations with low overheads and a track record of delivery.

Each Ambulance Trust operates entirely independently with its own management structures and support staff costs, and in most instances operates its own control room. Mutual aid arrangements exist between ambulance services and fire and rescue services.

Examples of existing or planned Joint Working

West Midlands Ambulance Service

West Midlands Ambulance Service (WMAS) shares a total of 47 operational sites with other emergency services. This includes the use of police and fire and rescue service sites as reporting posts for small teams of paramedics (community paramedic schemes), or as response posts for double-crewed emergency ambulances and paramedic rapid response vehicles to stand-by as part of WMAS’s deployment model.

· Co-location, co-responding and defibrillators

WMAS operational areas	Fire and rescue service station shared with ambulance service	Fire and rescue appliance fitted with AED	Co-responding schemes
Birmingham	15	60	0
Black Country	11	(combined with above)	0
Coventry and Warwickshire	8 (2 fire and rescue services cover West Midlands; Coventry: 4; Warwickshire: 4)	Coventry: 4 Warwickshire: 0	0
Staffordshire	32	47	1
West Mercia	1	21	0
Total	67	132	1

Specific examples:-

- Tally Ho (Police service) Event Control Suite – blue-light multi-agency site

- Birmingham Multi-agency Emergency Service Unit (MAESU) meets monthly to ensure all areas of emergency preparedness and special operations dovetail with each other

- Stafford Civil Contingencies Unit (CCU) – as above but office space shared on permanent basis

· Education and training

- Joint use of education resources between WMAS and other blue light services, including tri-services facilities at Ryton and Winterbourne Gunner

- Hazard Area Response Team (HART) operatives taught breathing apparatus (BA) and inland water skills by fire and rescue services

- WMAS delivery of triage training to BHX (airport) Fire and Rescue Ltd personnel

- Joint blue-light delivery of training: Marauding Terrorist Firearms Attack (MTFA); Multi-Agency Gold Incident Command (MAGIC); Chemical, Biological, Radiological and Nuclear Gold and Silver courses

· Exercising

- A number of joint exercises have taken place over the last 12 months; key exercises are:-

* Amber 1 (May 12) and 2 (May 13): national mutual aid exercises

* Annual major incident plan exercises: all three services

* MTFA exercises: on-going

* CBRN: on-going through ‘shield’ exercise process

* Exercise Triton: flooding

* Exercise Clean Care: National Atlantic Treaty Organisation wide (NATO)

London Ambulance Service

The London Ambulance Service (LAS) works closely with the London Fire Brigade (LFB) and Metropolitan Police Service (MPS). Examples include:-

· Delivery of medical training to British Transport Police: a Memorandum of Understanding (MoU) is in place for medical training for an initial response to incidents on the tube network; the LAS charges a nominal fee for this

· Defibrillators – City of London: a mature scheme is in place for City Police to respond to medical emergencies with Automatic External Defibrillator (AED) equipped cars and bicycles; 10-12 machines are in operation within the square mile; no cost is incurred by the LAS

· ‘Train-the-trainers’ in casualty care: the LAS has an MoU with the LFB to train-the-trainers in casualty care for cascade; on-going quality assurance provided by LAS consultant paramedic and senior trainers

The LAS is currently involved in on-going discussions with the LFB to explore future opportunities for collaboration with a view to reducing costs and improving efficiency. The focus will be on the following areas:-

· Estates: including potentially renting space in the LFB offices; shared or sole use of fire stations for operational ambulance/super stations

· Joint procurement: for assets such as fuel, stationary, IT equipment, vehicles etc.

· Support services: for example, Payroll, IT support etc.

Yorkshire Ambulance Service

Historically, the Yorkshire Ambulance Service (YAS) has had limited collaboration with police and fire services, however, existing pockets of effective co-working include:-

· Static medical units: joint-work with police services in city centres of Friday and Saturday nights

· Co-responding: ‘Polamb’ – police officer riding with rapid response vehicle in city centres (South Yorkshire and West Yorkshire)

· Training: medical training provided by ambulance services for police firearm units

· Clinical governance: introduced for fire and rescue services (Yorkshire and Humberside)

In addition, over the last six months, a formal process of engagement has commenced with blue light services to support quality of services and reduction in joint operating costs.

Proposals have been made to the joint Chief Fire Officer, Yorkshire and Humberside, in relation to:-

· Estate collaboration

- Procurement of new joint premises (South Yorkshire)

· Co-location of sites

- Joint services co-location (mainly standby at Pontefract, West Yorkshire)

- Future co-location (North Yorkshire Police co-locating at YAS site)

- Stand-by: ambulance service on fire service sites, including some 5 star stand-by cabins on fire and rescue service premises

· Fire service co-responding

- Pilot underway (Pocklington, Humberside) and further schemes being sought (South Yorkshire and Humberside)

· Support/back office functions

- Discussions underway with police services in relation to training facilities and shared back office functions (West Yorkshire)

Although the above are all in the early stages, the ambulance service chief executive officer and fire and rescue service and police counterparts have agreed that elements of the joint work outlined will be evident across all blue light services in the region. Once progressed further, the identification of cost savings will be sought, which is one of the driving motivators for co-working.

Summary

CFOA and AACE already have strong engagement at a national level to exploring opportunities for increasing the already good work being undertaken in most areas of the country

AACE supports the need for efficiencies in public sector organisations and is therefore committed to assisting others in realising efficiencies as ambulance services have already.

There are already strong examples of Blue Light Services working together e.g. Joint Emergency Services Interoperability Programme (JESIP) which is looking closely at how the services work more closely at serious and major incidents.

Both AACE and CFOA are committed to working together to take both Ambulance Services and Fire and Rescue Services forward in a sustainable way.

July 2013