Health CommitteeWritten evidence from Association of Ambulance Chief Executives (ES 19)
Summary
The Association of Ambulance Chief Executives (AACE) provides ambulance services with an organisation that influences, supports, co-ordinates and implements nationally agreed policy. It also provides the general public and other stakeholders with a central source of information about NHS ambulance services. AACE’s primary focus is the ongoing development of the English ambulance service and the improvement of patient care.
The Health Select Committee’s inquiry into emergency services and emergency care is welcomed by the AACE. The AACE is pleased to outline its thinking in the areas covered, a summary of which is provided below:
New commissioning arrangements provide an opportunity for:
enhanced integration of emergency and primary and community care, building on current close-working
exploration of new and different ways in which the ambulance service can contribute to the wider health system
more strategic commissioning of integrated services
The ambulance service is a key enabler in maximising opportunities to manage demand and increase efficiency; the sector must be embraced as part of the solution to the problem rather than being viewed as part of the problem
In light of the implementation issues experienced with the NHS 111 service to date, the AACE advocates serious re-consideration of the current arrangements including commissioning
The AACE fully supports the shift from response time to clinical effectiveness indicators; however, to fully maximise the impact of this, careful consideration should be given to both the benefits and disadvantages of clinical outcomes assuming the position of core performance measure, and Ambulance Clinical Quality Indicators (ACQIs) featuring in the national NHS Provider contract
There are a multitude of reasons for delays in ambulance to A&E handovers, which the ambulance service is well-placed to advise upon and is proactively seeking to tackle
1. Role of community and primary care in delivery of emergency healthcare; appropriate structure to meet demands of different geographical areas
New commissioning arrangements have the potential to facilitate enhanced integration of emergency, primary and community care. Clinical Commissioning Groups (CCGs) should seek more seamless care provision to improve the patient experience whilst reducing costs (for example, unnecessary A&E admissions). Commissioning arrangements should be strengthened with more comprehensive Directories of Services and patient pathways, utilised during the day and out-of-hours.
Close working between emergency and community and primary care services already exists. West Midlands Ambulance Service (WMAS) operates community paramedic schemes, which form a central component of its operating model and involve close working with general practitioners (GPs) in relation to patient pathways and identification of gaps in provision. Alongside community and primary care practitioners, ambulance services play a crucial part in the delivery of high quality end-of-life care and in enabling people to achieve what they would consider a good death, as recognised in the Department of Health’s End of Life Care Strategy (2008). The AACE is highly supportive of this integration across emergency and primary and community care, and its expansion where both patient benefit can be derived and cross-system efficiencies gained.
Other opportunities that should be explored include: utilising GP surgeries as potential “hubs” for voluntary community first responder schemes in a collaborative and complementary fashion with the ambulance service; and community and primary care services acting together with the ambulance service to better inform and educate communities about emergency healthcare, including cardiopulmonary resuscitation, to achieve an integrated and holistic response for rural communities. In order for ambulance services to continue to deliver more care in the community and home setting, the local network of community services needs to keep pace and be aligned with the developments in the ambulance service and vice versa; otherwise, opportunities, particularly in rural areas, will continue to be limited.
2. Moving minor injury and urgent care services out of A&E and into community; range, severity and incidence of conditions that can be treated within A&E but not an urgent care centre
Minor injury and urgent care centres serve a useful purpose and can help to ease pressure on A&E; they are best located where need is greatest, which in some instances will be in more accessible community settings. Alongside other health professionals, paramedics are well-placed to participate in the provision of minor injury and urgent care given their triaging and treatment skills. In some areas of England, there is, unfortunately, evidence of enhanced primary and community service provision being reversed. For example, all walk-in-centres across Manchester have been closed over the last 12 months whilst a considerable number of urgent care centre facilities are now located at the front door of A&E departments.
A significant proportion of conditions can be dealt with competently at a well-staffed, equipped minor injury and urgent care centre; examples of those that cannot include conditions requiring a paediatrician, obstetrician or anaesthetist. The major difficulty presented is determining the suitability of an urgent care centre for a patient’s medical needs without the benefit of diagnostic equipment. Experience gained in existing urgent care centres should be sought to help address this.
3. Better integration of ambulance services with primary care under new commissioning regime
The AACE is committed to and supportive of the statements outlined within the National Ambulance Commissioners’ Group briefing, “Integrated ambulance commissioning in the new NHS” (2012) (http://www.nhsconfed.org/Publications/briefings/Pages/Integrated-ambulance-commissioning.aspx).
However, this commitment and support is underpinned by a number of concerns. Firstly, 2013/14 feels very much like a “transitional year” as CCGs establish themselves and decide what contractual arrangements will exist in the future for ambulance services. Secondly, as CCGs have a different footprint to ambulance services, a system-wide approach is necessary to join up commissioning arrangements, service delivery and funding to support the delivery of integrated care across the whole health system. Finally, whilst the provision of emergency ambulance care is commissioned by CCGs, primary care is commissioned by Local Area Teams. This adds a further layer of complexity to enhanced integration of commissioning and delivery of emergency, urgent and primary care. CCGs must commission collaboratively when appropriate to achieve economies of scale whilst providing a higher performing urgent and emergency care service, particularly in rural settings.
Changes in commissioning arrangements also present a number of opportunities, which ambulance services can play a central role in maximising. The presence of GPs has enhanced the clinical focus at the contract table. The AACE and its member organisations are optimistic that this will shift the focus of future commissioning debate creating opportunities to explore new and different ways in which the ambulance service can contribute to the wider health system. Developments are already being identified locally by ambulance services that can be taken forward in conjunction with primary care. For example, South West Ambulance Service Foundation Trust (SWASFT) is providing an “in-hours” visiting service on behalf of GPs, packages of care, urgent care triage etc, which are all designed to better support the urgent care pathway.
The new commissioning regime provides an opportunity to embrace more strategic commissioning of integrated services. The focus should shift from commissioning the cheapest provider of individual parts of the pathway to consideration of integrated partnership solutions to urgent and emergency care pathways in their entirety. There is considerable scope to reduce duplication and waste, and subsequently cost, whilst significantly improving the provision of joined-up and streamlined services.
4. Ability of ambulance services to continue to meet increased demand whilst contributing to the Nicholson Challenge
The ambulance service is a key enabler in maximising opportunities to manage demand and increase efficiency. Ambulance services are exceptionally well placed to understand the causes of increasing demand and to develop solutions to co-ordinate a proportionate response. Huge increases in demand have been experienced nationally. In 2011/12, the total number of emergency calls was 8.49 million; this was an increase of 415,487 (5.1%) over 2010/11 when there were 8.08 million (www.hscic.gov.uk). Considerable investigation has been undertaken by services locally to understand patterns and changes, which the AACE will build on in an imminent demand management project focused on identifying national trends and determining solutions.
Ambulance services have repeatedly demonstrated their ability to become more efficient whilst saving money, and are committed to the continuation of this through investment in technology, training and transformational change. Utilisation rates are high for staff and vehicles, whilst back-office costs are low when compared to the broader NHS. Reductions in hospital conveyance rates have been achieved consistently over recent years. In 2009/10, 1.60 million patients were treated at the scene and did not need onward transportation; in 2010/11, this increased to 1.76 million; and in 2011/12, 1.81 million (www.hscic.gov.uk). However, this will not continue indefinitely, given the appropriateness of hospital for a significant proportion of patients, and will only be a sustainable trend if emergency capacity does not reduce alongside ongoing demand increases.
Contributing to the Nicholson Challenge in the context of ever-increasing levels of demand certainly presents a major challenge for the ambulance sector. However, the AACE strongly advocates that the sector is embraced as part of the solution to the problem. The ambulance service has the potential to further reduce hospital attendances and admissions through better trained and equipped paramedics delivering more comprehensive care in the community. To fully realise the benefits of this, additional investment will be required. This investment would drive efficiencies in the overall system whilst enhancing the delivery of timely, appropriate care to patients. Unless demand is matched with growth in funding, the ambulance service’s ability to continue to deliver efficiencies at the pace required will be severely limited, particularly given that this will increasingly require fundamental changes to service delivery.
5. Transition from NHS Direct to NHS 111
NHS 111’s recent rollout has seen a mixed reaction, which has been driven by a combination of poor operational performance from some providers leading to significant adverse media fuelled by the inappropriateness of responses. This has been compounded by a significant shortfall in some providers meeting the core performance call-answering metric and high abandonment rates.
Continuing poor and inappropriate performance has the potential to harm public confidence in the 111 service before it has had the opportunity to become a credible offering and is fully embedded. There is now a real and immediate opportunity for the Department of Health/NHS England to act quickly to resolve the continued unease around 111. The arrangements should be reviewed in order to restore public confidence.
Were the ambulance service to assume a more significant role in national 111 provision, the potential benefits would include: confidence in a universally recognised professional, experienced and capable function; whole system effectiveness and value for money; and appropriate management of demand across the urgent and emergency care system. The ambulance service is already held in high regard by the public and is uniquely placed to potentially deliver NHS 111 to ensure high quality service provision for patients and cost effectiveness across urgent and emergency care.
6. Shift from indicators based on response time to clinical effectiveness
The AACE supports the shift to clinical indicators and the drive to promote consistency across the sector. It advocates the simultaneous maintenance of response-time targets, however, because of the value they add as a determinant of outcome and patient experience. There is potential scope for the removal of response-time targets to have a profound impact upon resource efficiency and clinical outcomes. Prior to any move in this direction, comprehensive research and extensive interrogation of the overall impact upon patients is strongly urged.
The commissioning, contract negotiation, management and regulation of ambulance foundation trusts is currently underpinned by a focus upon response times. There has been some move towards combining this with shadow currencies for activity growth in “hear and treat”, “see and treat” and “see and convey”. Thresholds for ACQIs are still agreed and performance-managed by commissioners locally, however. A fundamental shift away from response times to more outcome-based measures would need to see ACQIs featured in the national contract with the standardisation of thresholds for each ACQI to ensure consistency of measurement across all services.
7. Causes of delays in ambulance to A&E handovers or transfers within urgent care
Delays are a major everyday issue for ambulance services. The causes are multi-faceted and vary from hospital to hospital, and health system to health system. Examples include: ownership by hospital/health system leaders; A&E capacity; A&E integration with the rest of the hospital; timeliness of in-Trust escalation; reductions in physical bed capacity within hospitals and the community; attitude and behaviour towards handover delays within the hospital; and the effectiveness of urgent care pathways keeping demand away from the front door.
Ambulance services are well-placed to provide a range of timely data in relation to handover delays, however, identifying the “softer” issues, such as senior leadership, ownership and operational grip is more problematic. The successful addressing of ambulance to A&E handovers in the past has largely been attributable to strong relationships between clinicians and managers in the hospital and the ambulance service.
Recently, ambulance services have trialled a range of new approaches to deal with the issues faced. These include revision of local hospital handover delay arrangements to include an appendum to the handover escalation protocols (SWASFT); a number of summits for all NHS directors and operational leads across geographical areas to discuss the issues and short and longer term solutions; and the establishment of a local turnaround collaborative in Yorkshire. The introduction of penalties for hospitals failing to manage handover/turnaround activities is likely to improve issues in the short-term, but longer-term solutions will require an assessment of local healthcare provision capacity and demand across emergency and urgent care.
8. 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
There is good evidence of the positive impact of specialist regional centres upon clinical outcomes, including trauma, stroke and STEMI. This has driven the development of vascular centres and current consideration of cardiac arrest centres. If 24-hour-a-day staffing by experienced, competent professionals is to be ensured, there is a requirement for realignment of generalist hospital-based services as more specialist regional centres are introduced.
9. Effectiveness of existing consultation process for incorporating views of local communities into A&E service design
A&E service design often presents too emotive a subject for constructive dialogue to be of value. Processes are reportedly fragmented, bureaucratic and complex. Particular regard needs to be paid to the use of social media and the use of alternative consultation channels to access a broader spectrum of views, including those of young people.
10. Ability of local authorities to challenge local proposals for reconfiguration under revised oversight and scrutiny powers included in Health and Social Care Act 2012
It is still too soon for this to be tested given the very recent introduction of the legislation. However, local authority powers seem appropriate to challenge and review proposed reconfiguration proposals. Local government needs to ensure that the challenge of local versus regional priorities is balanced.
May 2013