Health CommitteeWritten evidence from West Midlands Ambulance Service NHS Foundation Trust (ES 04)
1. Introduction
West Midlands Ambulance Service NHS Foundation Trust (WMAS) is the statutory NHS ambulance service that covers Staffordshire, Warwickshire, West Mercia and the Birmingham and Black Country conurbation, a population of 5.6 million people. The Trust employs over 4,000 staff and responds to around 760,000 999 calls every year. The main measure of ambulance service performance is the time taken to respond to patients who are assessed as potentially life-threatened during the 999 call. The targets are to reach 75% of these patients within 8 minutes and 95% within 19 minutes. WMAS is achieving these targets at 75.5% and 97.3% respectively.
WMAS’s vision is to deliver the right patient care, in the right place, at the right time, through a skilled and committed workforce in partnership with local health economies.
It has four key strategic objectives:
Achieve Quality and excellence.
Accurately assess need and direct resources appropriately.
Establish market position as an emergency healthcare provider.
Work in partnership.
The Trust was authorised as a Foundation Trust on 1 January 2013.
Key developments include:
moving towards a target of 70% of frontline staff who are Paramedic trained. This will ensure that every patient can be guaranteed to receive Paramedic care which will increase the proportion of patients treated at scene and therefore reduce the number of patients conveyed to Emergency Departments; and
progress towards a Community Based Ambulance Service through the use of a “hub and spoke model” in which ambulances are serviced and equipped centrally and sent out to strategic locations (almost double the number of the previous stations) from where they can respond quickly to predicted need.
West Midlands Ambulance Service NHS Foundation Trust (WMAS) welcomes the Health Select Committee’s inquiry and the opportunity to contribute to the Committee’s thinking. This submission addresses those of the Committee’s questions that are most relevant to ambulance services and outlines opportunities for ambulance services to streamline patient pathways, prevent duplication and improve communication to both patients and commissioners, thereby improving outcomes and reducing inequalities. Through this paper we cover:
The contribution that ambulance services can and do make to providing urgent and emergency care and treatment in the right place, potentially avoiding unnecessary visits to hospital.
The scope for more sophisticated commissioning across organisations to lead to improved care and to financial efficiency.
The potential for ambulance services to work more closely with primary and community care services in ensuring that care takes place in the right place.
The work of ambulance services in preventing unnecessary admissions and providing definitive care.
The role of ambulance services in ensuring that seriously ill and injured patients receive the most expert care.
2. Role of community and primary care in delivery of emergency healthcare; appropriate structure to meet demands of different geographical areas
WMAS believes that there is scope for community and primary services to become more involved in the provision of emergency healthcare and in the prevention of medical emergencies. There is huge scope for better integration of ambulance services with primary care. Many 999 patients are frail, elderly, near the end of life or have multiple or chronic complaints eg diabetes and dementia. Good primary and community care can provide support for such patients and prevent the exacerbations of conditions that can lead to emergency admissions. WMAS is involved in a number of initiatives in cooperation with primary care, for example:
Community Paramedics attend GP practice meetings to ensure that they understand the needs and care plans of particular patients with long term conditions, thus ensuring that they are not admitted to hospital unnecessarily.
Work with GPs and other providers to review patient pathways and ensure that gaps in provision are identified and addressed. For example, where WMAS has identified a high number of patients who have called 999 following a fall which has not resulted in injury, they have worked with commissioners and other providers to introduce Falls Cars operated by a single Paramedic thereby avoiding deployment of a double crewed, fully equipped ambulance.
WMAS maintains an End of Life register for patients in Worcestershire to ensure that ambulance crews are aware of patients who are at the end of life and the arrangements that have been made between clinicians and patients. This means that patients’ wishes for their treatment are respected.
Initiatives such as the falls cars described above, GPs in rapid response vehicles and giving Paramedics permission to prescribe antibiotics have all been effective in reducing hospital admissions and conveyance to A&E. As a result of these and other initiatives WMAS reduced conveyance rates from 70% to less than 58% between 2009–10 and the end of 2012–13.
In addition to the treatment of patients, we work closely with commissioners to develop educational material to advise patients who are at risk of accidents and illness about avoidance and management of conditions, through this patients are able to avoid calling for an ambulance or GP visit.
Despite these initiatives WMAS staff are frequently called as a last resort for patients who cannot understand or access the services that are available to them.
The question of how services are structured may be less important than the commitment to work together, whatever the structures. Several services, eg out of hours primary care, district nursing and health visiting have some similar features to ambulance services, such as being mobile and receiving urgent contacts by telephone. The ambulance service has developed region-wide, robust mechanisms for receiving calls, triaging them quickly and sending speedy responses. Learning from the ambulance sector, joint ventures and sharing of resource and information could vastly improve the efficiency and effectiveness of primary care services in responding to patients.
3. Progress towards moving some minor injury and urgent care services out of A&E and into more accessible community settings
WMAS believes that Minor Injury Units serve a useful purpose and should be located where need is greatest, which in some cases may be into more accessible community settings. It is helpful to recognise that the location, nature and volume of need changes according to time of day and day of week. WMAS has had some success with a mobile Paramedic unit that can be located in areas of high footfall and incidence of injury—for example Birmingham City Centre on Saturday evenings.
WMAS considers Paramedics to be well placed to provide minor injury and urgent care services in alternative locations alongside other health professionals. Paramedics are able to triage effectively and have the skills and training to treat a wide range of illness and injury. This initiative could be a key part of providing these services.
4. Prospects for better integration of ambulance services with primary care under the new commissioning regime
WMAS has not yet seen significant change in the way services are commissioned under the new regime, but believes that there is considerable scope for this.
CCGs in the West Midlands have opted for a lead commissioner arrangement for the ambulance service: one individual is jointly funded by all 22 commissioners of the service to develop expertise and lead negotiations although all CCGs are required to sign the contract. This is cost effective and also means that the service receives more expert and concentrated attention.
WMAS believes that there is a need for clearer and more strategic commissioning of integrated services from partnerships of organisations that provide emergency and urgent care. The current situation, in which organisations are commissioned separately, leads to a concentration on reducing cost and increasing productivity within each organisation. This is useful as far as it goes, but an integrated approach would improve patient care and avoid duplication and waste across the system.
Close working relationships and sharing of data and information between ambulance and primary care providers could improve patient outcomes, reduce acute admissions and also avoid the cost incurred in the process of discharging a patient after an avoidable acute admission.
The ambulance triage system, NHS Pathways, generates information that could be used by commissioners and primary care providers. The information can demonstrate unmet need of patients with particular conditions and also where services are not provided at the correct times of day or in the most appropriate location. The Directory of Services for the West Midlands which is a key component of NHS Pathways contains information about all community services, their eligibility criteria and hours of operation. It was developed and is maintained by WMAS. Gap reports are provided for commissioners and these could help commissioners to target resources to the areas and patients with the most need but as yet little action has been taken to act on the information provided.
5. Ability of ambulance services to continue to meet increased emergency demand whilst contributing to the Nicholson challenge
WMAS has delivered savings of between 4 and 5% of turnover in every year since 2010/11 and plans to continue to make similar savings for the foreseeable future. It is funding the increased number of Paramedics from further internal savings, rather than from extra income. High levels of utilisation can be demonstrated for both staff and vehicles and the back office functions of ambulance services are comparatively low for the NHS, typically being about 15% of the costs base compared to 20% in an acute trust.
Nonetheless, 999 demand continues to increase by 4.5% a year in the West Midlands. It will be necessary to continue to respond, usually by sending a Paramedic. WMAS Commissioners have recognised this reality in the negotiations for the 2013/14 contract.
It is unlikely that ambulance services will be able to offer further savings to the Treasury in the short term. But they are a potential source of considerable savings to the NHS as a whole. Advanced Paramedics, who have further training and equipment, are able to provide care outside hospital and prevent unnecessary attendances (and therefore the associated costs). For example in the West Midlands:
Urinary tract infection: Until recently, most patients with these infections were taken to hospital for the condition to be fully diagnosed. But Advanced Paramedics are now able to carry out a simple test at the scene which allows diagnosis. The patient can then pick up a course of antibiotics from their GP without the need to go to hospital.
Gluing of wounds: Previously patients with lacerations were taken to A&E to have the wound glued, steri-stripped or stitches applied. Advanced Paramedics are now able to glue and steri-strip lacerations at scene once more reducing the need to take patients to hospital.
6. Transition from NHS Direct to NHS 111
WMAS fully supports the national policy for the introduction of NHS 111. However, experience to date in the West Midlands has been poor due largely to inadequate commissioning and implementation. Insufficient focus was placed on the resources required to deliver a safe and effective service at the outset and throughout implementation and this has resulted in a significant shortfall performance which has led to poor patient experience, unnecessary pressures on Ambulance and Emergency services and lack of public confidence in the 111 brand.
7. Shift from indicators based on response time to clinical effectiveness
WMAS welcomes the move towards new clinical effectiveness measures and has been instrumental in developing these. A focus on outcomes for a range of conditions means that they receive greater attention. All ambulance services are required to submit performance data and WMAS aims for the upper quartile of performance for all of these indicators.
However, fast responses will still be needed for these and other patients, so it has not led to a loss of attention to response time targets.
8. Causes of delays in ambulance to A&E handovers or transfers within urgent care
The causes of delays and transfers are many and varied. WMAS has experienced an increase in demand which has an impact on the number of patients being taken to A&E. Once there ambulance crews witness a lack of clarity and/or willingness on the part of hospital staff to engage fully in the handover process which leads to delays. The lack of capacity in A&E units to deal with demand and particularly surges in demand seems to be a factor.
Ambulance services will continue to seek to reduce the numbers of patients they take to A&E departments. This can be achieved through telephone triage and having alternative services to which patients can be referred, through staff having the skills to make the right decisions for patients and through admission avoidance schemes and alternative pathways of care.
As described earlier, WMAS has a reduction in the proportion of patients conveyed to hospital by more than 12% in recent years and aims to reduce conveyance rates to 52% by 2015/16, but the rate of reduction is slowing and will continue to do so. In due course it may not be possible to reduce further the proportion of 999 patients that are taken to hospital.
Whilst imposing financial penalties on hospitals for turnaround delays may have a positive short term effect on behaviour, it does not resolve what seems to be a problem of lack of resource planning and utilisation in A&E units.
9. Clinical evidence about specialist regional centre outcomes compared with more generalist hospital based services; aspects of care likely to improve if moved to specialist regional centres
International evidence exists showing improved outcomes for patients with ST Elevation Myocardial Infarction heart attacks if they are taken to places that can provide primary coronary interventions such as angioplasty 24 hours a day. Similarly, survival from stroke improves when diagnosis and intervention is rapid. Major trauma patients benefit from being treated by specialists who are geared up to providing the surveillance and care for patients in recovery. In this case survival rates may be 20% higher.
The Midlands and East SHA undertook a Stroke review in 2011/12. This review recommended the centralisation of a number of current stroke providers to ensure a safe and sustainable 24/7 service within Midlands and East. WMAS supports the implementation of any such change by ensuring that crews are trained and empowered to take patients to specialist unit.
The Regional Trauma Network in the West Midlands went live in March 2012. There are four Major Trauma Centres (MTCs) and a network of supporting Trauma Unit hospitals across the region.
WMAS has a Major Trauma Desk staffed by Critical Care Paramedics who are responsible for liaising with crews to ensure that trauma patients receive optimum clinical care and are conveyed to the most appropriate treatment centre for their presenting condition. The CCPs are able to offer clinical advice, give support to crews regarding the treatment of patients and advise on the choice of destination hospital. They are also able to put crews in contact with an experienced pre-hospital doctor who will be able to speak to crews, offering advice and support 24 hours a day, 365 days a year. CCPs receive an average of 7 calls per day to the Major Trauma Desk.
May 2013