(Director of Governance) To undertake appropriate scrutiny of the East of England Ambulance Service NHS Trust in response to the concerns of members with regard to local ambulance services provided across the Epping Forest District.
The Chairman introduced Alan Whitehead the Sector Head of Service Development, Engagement and Improvement from the East of England Ambulance Service NHS Trust. He was there to facilitate the scrutiny of the East of England Ambulance Service NHS Trust in regard to local ambulance services provided across the Epping Forest District, following the publication of a Care Quality Commission (CQC) report in August 2016 and its judgement that the quality of the service provided by the Trust required improvement.
Members had submitted some advanced questions that were sent to him beforehand to enable him to prepare answers for the meeting.
Mr Whitehead thanked the Committee for inviting him to the meeting and noted the 13 questions he was sent in advance. He took the first three questions first. They were:
· the plans of the Trust to address a report of the Care Quality Commission (CQC) (August 2016) on its judgement that the quality of the services provided by the Trust ‘requires improvement’;
· the current position of the Trust in addressing the concerns raised by the CQC in August 2016;
· the arrangements of the Trust for stakeholder and public reporting of its progress in addressing the concerns raised by the CQC;
He noted that the trust worked to an action plan in response to the CQC report. As a result of this many improvements have been put in place especially in medicine management, health and safety and feedback to staff. They reviewed their policy and procedures on medicine management to ensure they were consistent across the region. The Trust covered six counties and had to harmonise their procedures. Their action plan was also published on the website to be reviewed and commented on. Their aim was to be the best provider of care and used the CQC report to support this improvement.
The last CQC visit was just over 18 months ago. They concentrated on “core services” and on how “well led” they were. Feedback so far on the improvements has been broadly positive, with some areas to improve on. They will now feed this back to the CQC with their action plans. The trust was not advised to make any immediate changes during the inspection. Once they have the outcome of the report later this year they would share it, as would the CQC.
The next two questions were:
· the geographic area for which ambulance services are provided by the Trust and its current response and attendance performance in relation to emergency calls across its operational area;
· the current response and attendance performance of the Trust in relation to emergency calls received across the Epping Forest District;
The trust covered six counties, with a population of nearly six million people and provides a range of services. Best know for the 999 emergency services, where they provide a 24/7 service. In 2017 to 2018 they received 1.1million calls across the region. As for performance, since October 2017 they had introduced the Ambulance Response Programme (ARP) in line with other ambulance trusts in the country. The aim was to maintain the operational efficiency of the ambulance service while focusing on the clinical needs of the patient, which was their real key as an organisation. They had three main objectives, prioritising the sickness patients to ensure the fastest response; delivering appropriate operational behaviours so that the patient got the appropriate response the first time and in an appropriate time frame; and by putting an end to unacceptable long waits.
They were now also for the first time measuring the mean rather than the average response times. Also a time standard would apply to every patient to whom a vehicle was sent; previously this was not always the case. They were now reviewing how they dispatched ambulances or their fast response cars. Also their new model would be for more double staffed ambulances and slightly less fast response vehicles. Their priority was to transport patients (to hospital) and therefore it made sense to have ambulances. A new set of quality indicators would measure the time between receiving a 999 call and receiving life saving treatment for heart attacks, strokes and cardiac arrests. This was all designed to ensure that the sickest patients received the fastest response, get the response they needed the first time and in a time frame that was appropriate to their need. Also people living in rural areas should receive a more equitable response as they spread resources more equally amongst patients.
They have had to rewrite all of their reporting programmes over the last few months, but this had meant that they were not reporting performance against new targets because of this transitional period. But, they will be able to start reporting performance by the end of this month; so they can supply figures to any future meeting if required.
The next question was about the resources and capacity of the Trust to respond to emergency calls received across the Epping Forest District.
The West Essex area contains Harlow, Epping and Loughton. They currently had 167 staff and 16 vacancies which did not affect their ability to meet their contractual obligations. This was supported by some purchased private resources and if required by the surrounding area Trusts. They have recently had an Independent Service Review looking at the gap between demand and resources. They have done some modelling and researched target and have now had a report back from external consultants; the result would indicate an increase in resources over the next two years.
He was asked about the Trust’s call handling arrangements for emergency situations arising across the Epping Forest District. Their call handling procedure was the same across the region. They operated three emergency control rooms, one at Norwich, one at Bedford and one at Chelmsford. Any calls will be triaged by the call takers to enable them send the right resource to any call received. They now have 90 seconds to triage a call, before that it was only 30 seconds; this would enable them to allocate the most appropriate resource to that. There was two ways to deal this this from then on, it could go to the ambulance dispatch desk where the nearest resource could be dispatched to the patient, or it could go to their emergence advice and triage desk where they have a number of clinicians, specialist in various areas, where they can assess their need, offer advice, and sometimes maybe send an ambulance or send a paramedic out to do a face to face assessment or any other appropriate advice.
Calls are now categorised into four different categories, referred to C1, C2, C3 and C4. A C1 call was an immediate life threatening call; this has recently been broadened out to catch more people and circumstances under this category.
He was also asked about the Trust’s complaint handling arrangements for emergency calls received across the District. As a Trust they welcome complaints (as well as compliments). They can be made in a number of ways and will be passed to the ‘Patients Experience’ department in Bedford where they were monitored. Their policy was to complete all complaint investigations within 25 working days, however if it took longer they would go back to the complainant and explain why. The Trust will follow up and analyse any serious incidents that had occurred.
They also have a patient experience survey to monitor the patient feedback and recently noted that in September 2017, 100% of the people surveyed in Essex would be extremely likely to recommend the emergency services again.
The next question asked was to do with the operation of public forums by the Trust for feedback on its local ambulance services and the consideration of relevant service performance issues. They have a Community Engagement Group whose members are made up from the general public from across the region. It should be noted that in January and February they received the highest number of compliments in recent times.
He was also asked about the provision of cross-border ambulance services by the Trust, to other NHS Trust areas and also on the operational procedures of the Trust, specifically with regard to the initial attendance of paramedic or ambulance services in response to emergency calls received across the District. Like other trusts they did not have internal boundaries. For each 999 call they receive, the nearest response vehicle would be dispatched. At times the ambulance could convey patients to facilities outside this operating area, such as to a specialist hospital to better support a patient with major trauma. They also transfer patients to other areas of specialist care, such as to London when considered necessary. Lesser priority patients may also be diverted to other hospitals if the main ones were experiencing high workloads or major incidents. Nationally they have cross border arrangements, which mean that a nearer resource could be sent, say from London if they were closer and available. Also in times of major incidents they can assist London, such as the Grenfell Tower fire. What that meant was that we covered for the London ambulances that were sent there.
The next question asked was about the current provision of non-emergency Patient Transport Services (PTS) by the Trust. Their patient transport team make about half a million journeys a year taking patients onto other specialist hospitals, or to and from appointments to other facilities etc. this was a high quality service for patients, safe and flexible. Last year they were asked to take over the PTS contract for Hertfordshire and Bedfordshire when a private company went into liquidation. They had to take this over at very short notice and had to put in arrangements over a weekend; which they successfully managed to do, taking on staff on a temporary basis from that contract.
The last question was on current areas of ‘stress’ within the provision of ambulance services by the Trust, including any issues of specific relevance to the Epping Forest District. As with most public sector authorities they had a number of issues, finance being the obvious one. Another one was about ambulance arrival to handover times, it should be 15 minutes; the majority of delays occurred from arrival to handover and they were looking to improve that process, having monthly meetings with the team looking for improvements. Princes Alexandra has made remarkable improvements over the last six months on this. They have also seen an increase in demand for their services; over the last ten years they have seen an annual increase of approximately 1 to 2%. They appreciate that they cannot keep throwing money at the system and were now looking at how they worked with CCGs and other health partners and redesigning some of their services to make the most efficient use of their systems. Another problem was that their workforce was in demand; the paramedics have now a large skill set and other parts of the health service were recognising these skills and now paramedics were being enticed to work in GP surgeries and emergency departments etc. They were looking at this. It may be that instead of sending a patient straight to hospital, a paramedic could do a face to face assessment and refer them elsewhere in the system to a place of most appropriate need. They were trialling putting in emergency practitioners into GP practices, which are also stretched, and using them for home visits, helping to keep patients at home rather than a wasted journey to the local A&E department. They were also looking at other schemes one being around mental health street triage.
The meeting was then opened up to questions from members.
Councillor Neville asked about the high vacancy rate of 14% in the emergency care department, has that now come down, and given that, what was staff morale like? Mr Whitehead said it was the emergency control centres that he was referring to. He did not have the exact figures but was aware that they had increased although they were still struggling to find staff; so they still had some vacancies. Morale was always difficult to measure, unsocial working hours, large workloads and the breaks were always key to this and management was keen to address these issues. They were also consulting the staff to come to a working arrangement.
Councillor Mitchell asked if there was a child not breathing properly and they were only 10 minutes from hospital, what would be your response. Mr Whitehead said he would expect to send an ambulance to take them to hospital. If you are referring to a specific case please contact me after the meeting.
Councillor Patel said he spoke about mental health triage; he would also like the trust to look at support for social isolation in the community. The ambulance staff may well identify such people when they are called to attend them. Did they have something in place to escalate this to say, social services. Mr Whitehead said that was a good point as they often were the point of first contact and the eyes and ears of social services. Safeguarding was very important and their staff were well educated in this regard. They have a single point of contact that the staff can call and make a referral to the safeguarding scheme. More work was being done on this but it has not been publicised as much.
Councillor Patel then asked who monitored the safeguarding areas and how were they investigated and what were the outcomes. He was told that it was their duty to report any concerns they found and this was monitored. They also now get feedback on the cases reported. A lot of this safeguarding data was on their website.
Councillor Lea praised the excellent service she had received recently during a family crisis. However, she noted that there may be a lot of people who were taken to hospital who maybe did not need to go there, where the paramedics had to stay with the patients until the hospital took over. This was a waste of their time. Can a paramedic ask for a GP to come out instead of taking them to hospital, how would this work? Mr Whitehead replied that they can refer a patient to a GP and request them to attend. As for taking patients to A&E, there has been a lot of scrutiny over this recently. Of the calls that they receive and respond to, 65% were not conveyed to a hospital. They triage their patients and have other options other than taking them to hospital.
Councillor Wixley asked if there were doctors on some ambulances as there were now more ambulances and fewer paramedics now sent out. Were paramedics more skilled than ambulance staff and in which circumstances would you use an ambulance or a rapid response vehicle? He was told that a paramedic on an ambulance was the same as a paramedic in a response car and they often rotated between the two. There were some ‘critical care’ paramedics in ambulances and in rapid response vehicles. They were not looking to reduce resources as such; there will be more responding resources within the system and not less. The response cars were very much focused around achieving a target, but they now had more critically ill patients in this target so it was better having an ambulance to transport them.
Councillor Murray noted that in February the Chief Executive of the Service said that they needed 160 new vehicles over the next two years. Would this target be met? Mr Whitehead said he was referring to the Independent Service Review commissioned by the CCGs, and this was what was recommended. An outcome of this was that the CCG has agreed to fund this and we should get these vehicles over the next 2 or 3 years. But they will also be looking to us to deliver our side of the improvements required.
Councillor Sartin asked if they would also get the officers needed to man those vehicles. She was told that they were working with various universities to attract students to work with them and we can support them over their course. Plans were being put in place.
Councillor Bedford asked Mr Whitehead where he saw the ambulance service going to in the next ten years, would there be greater use of technology, would there be paramedics on motorbikes and was the Trust making better use of first responders in the communities. He was told that they had an active first responders programme and they were now equipping them with radios which also enabled them to track their positions. For each area they had a first responder manager. As for motorcycles they were a quick response but they were moving more to a transferable system for patients and would need more than motorcycles for this. Also there was a certain risk in using motorcycles, the riders needed specialist training and it could cost more than a quick response car, so they had decided that they were not viable for use. As for technology, they were always looking at this, but the main barrier was money. His area had a technology sub-group and they were looking to go paperless by 2020 and to equip staff with tablets to use. However the cost of rolling out new technology over the various CCGs in the region was very large.
Councillor Baldwin asked about the front line responders, did they have access to patient’s medical records. He was told that no, they did not, but there were some instances where they could be accessed; if their GP surgery had signed up to the appropriate system. They were working on this for the future.
The Chairman thanked Mr Whitehead for coming and giving such complete answers to the questions. She noted that the caring nature of the staff came through in the report in dealing with people in often difficult circumstances. Mr Whitehead replied that he would be happy to arrange a visit to a local station if asked.