Key areas of interest for paramedics in 2018

My Post (11)The most substantial development concerning paramedics this year is prescribing. Proposals to introduce independent paramedic prescribing were made to the Commission on Human Medicines (CHM) in 2015. However, the CHM did not support the proposals at that time. The College of Paramedics and NHS England went back to the CHM in July 2017 with case studies and an implementation plan to try and get further discussion. The following December the CHM decided to support independent prescribing by paramedics. It will now recommend implementation by making a submission to government ministers.

There is still a lot of work to be done and this is likely to be the key area for development of the profession in 2018. Legislation changes need to be made to enact the recommendation. Universities will have to develop their prescribing programmes and the Health and Care Professions Council (HCPC) will need to update its Standards for Prescribing. While it is unlikely there will be any paramedic prescribers until 2019 at the earliest, this marks a key progression in the development of the profession.

In September 2017, the HCPC began consulting on the threshold level of qualification for entry to the register for paramedics. The current level is outlined in the HCPC Standards of Education and Training at ‘equivalent to Certificate of Higher Education for paramedics’. However, the Paramedic Evidence Based Education Project (PEEP) report recommended the level to the paramedic register be raised to BSc (Hons) degree by 2019.
The consultation document proposes the level of qualification should be amended, due to the changing nature and complexity of the role of paramedics, and it illustrates the ongoing diversity in current qualifications across the UK. Any resultant change would not affect existing registered paramedics or students who are part way through pre-registration education and training programmes. The consultation closed on 15 December, with the outcome expected early this year.

Clinical practice

The UK Ambulance Services Clinical Practice Guidelines, last published in 2016, published supplementary guidelines last year. Although there will not be a new version of the guidelines this year, ongoing updates continue to be published online.

The National Institute for Health and Care Excellence (NICE) is updating its Quality Standard on Trauma. This quality standard covers assessment and management of trauma (complex fractures, non-complex fractures, major trauma and spinal injury) in adults, young people and children. It does not cover hip fracture or head injury as these topics are covered in a separate Quality Standard. The draft quality standard was open for consultation from 7 November to 5 December. The final Quality Standard is expected to be published on 29 March 2018.

Initial results from the AIRWAYS-2 trial are likely to be seen in spring 2018. This randomised trial is comparing the clinical and cost effectiveness of the i-gel supraglottic airway device with tracheal intubation in the initial airway management of patients suffering an out of hospital cardiac arrest.

At the time of writing, the final publication of the College of Paramedics’ position statement on paramedic intubation is still impending. Work began in May 2017 on the statement, with a group meeting in July to discuss and develop a first draft. This statement was reviewed and amended by several key clinical groups before being released to the membership and wider stakeholder organisations for comment. Consultation ran in September 2017, with final publication imminent.

Service delivery

NHS England and NHS Improvement have called on all A&E Delivery Boards to implement measures to reduce the impact of ambulance handover delays. They have outlined key principles concerning actions to be embedded as part of normal working practice, and actions to be taken should ambulances begin to queue.

Among the principles, they state acute trusts must always accept the handover of patients within 15 minutes of an ambulance arriving at the emergency department; that leaving patients waiting in ambulances or in corridors supervised by ambulance personnel is inappropriate; and that the patient is the responsibility of the emergency department from the moment that the ambulance arrives, regardless of the exact location of the patient. It will be interesting to see if the implementation of these measures will have an impact on reducing ambulance handover delays in 2018.

Ongoing feedback on the roll out of the Ambulance Response Programme (ARP) will continue throughout the year. The ARP saw changes to the triage of calls, known as dispatch on disposition, to allow more time for call handlers in cases that are not deemed as immediately life-threatening. Additionally, new call categories were introduced to better reflect the wide range of needs patients have when they dial 999. It is likely there will be national updates on the effectiveness of the ARP, hopefully with benefits of the change being seen, in 2018.

The NHS was promised £1.6 billion for 2018/19 and £900 million for 2019/20 in the autumn budget. While this is certainly welcome relief, it is still a far cry from the £4 billion health experts said the NHS needed. It is believed £1 billion of the cash pot for 2018/19 will be used to improve performance against the 18-week target for elective treatment and £600 million to help hospitals meet the 4-hour target in A&E.

Conclusions

These are just a few of the elements that will affect paramedics this year. Other areas not mentioned include the Assaults on Emergency Workers (Offences) Bill 2017–19, development of the nursing associate role, the national programme to support allied health professionals to return to practice, and the final report of the Asthma Audit Development Project. There are many challenges facing the NHS in the coming year, but with the upcoming developments in the profession, paramedics will find themselves in a key position to alleviate many of these pressures.

Taken from Journal of Paramedic Practice, published January 2018.

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Is now the winter of our discontent? Exploring seasonal pressure on the NHS

My Post (1)Around this time every year, the media is strewn with forewarnings of how winter will put undue strain on the NHS. In a system already struggling to cope, there are concerns that the seasonal pressure pushes services to breaking point. The NHS’s ability to handle yearly increases in demand has led the British Red Cross to go as far as to call it a ‘humanitarian crisis’ (Campbell et al, 2017).

This article will consider the causes of winter pressure on NHS services and how they differ to those experienced throughout the rest of the year. It will explore whether the warnings are genuine or mere hyperbole, and look at some of the ways the NHS attempts to combat these pressures.

Causes of winter pressures

The leading cause of winter pressure is difficult to pinpoint, and can vary from year to year. However, there are a number of recurring contributing factors. While most health problems are not caused by extremes of cold, the weather indelibly has an effect on the number of patients attending accident and emergency (A&E) departments.

Cold weather increases the risk of heart attacks, strokes, respiratory illnesses, flu, falls and other diseases (NHS England, 2013; Public Health England, 2017). Vulnerable people— such as the very young, elderly and those with pre-existing conditions— are those predominantly affected by changes in the weather (National Institute for Health and Care Excellence (NICE), 2015). The effect of winter on the NHS becomes apparent in early December. Performance in A&Es is measured through their ability to meet a 4-hour waiting target. One of the core standards of the NHS Constitution states that a minimum of 95% of patients attending A&E departments in England must be seen, treated and then admitted or discharged in under 4 hours (NHS England, 2015). Breaches of the 4-hour waiting standard result in trusts having to pay penalties (House of Commons Health Committee, 2016).

A&E attendances
Annual attendances at A&E departments have increased. The number of people arriving at major (type 1) A&E departments has seen a 7% rise from 2010 to 2015—from an average of 36 731 attendances per day in August 2010, to 39 220 in August 2015 (Fisher and Dorning, 2016).

Consequently, only 87.9% of patients in type 1 departments were admitted, transferred or discharged within 4 hours in 2015–16 (House of Commons Health Committee, 2016). This is clearly far below the expected standard. The Royal College of Emergency Medicine (2016a) has estimated that the increased attendance over the past 5 years is equivalent to the workload of 10 additional medium sized emergency departments.

Contrary to expectation, the highest number of A&E attendances does not take place in winter. Instead, there is an observable ‘dip’ in visits to A&E around December and January (Fisher and Dornin, 2016). The highest overall attendances are actually in the summer months. The important factor affecting winter pressure is the number of patients subsequently admitted to hospital. The highest proportion of the patient population in summer is under 60 years of age. By contrast, in the winter, it tends to consist of those over 60 years. This spike in the number of more vulnerable, elderly patients is significant because they tend to stay longer in A&E, and are more likely to be readmitted to hospital (Fisher and Dornin, 2016).

Hospital admissions
Like attendances, hospital admissions have also increased. Similarly, they have seen a 7% rise from 13 723 in August 2010 to 14 666 in August 2015 (Fisher and Dornin, 2016). There is a notable ‘peak’ of admissions during the middle of winter (Fisher and Dornin, 2016).

The difference between the proportion of patients admitted is 27.9% in winter, compared with 25.8% in the summer months (Department of Health (DH) et al, 2017).

‘Congestive hospital failure’
The rise in hospital admissions has caused a subsequent decrease in the number of available hospital beds, with the percentage of beds occupied peaking in winter (Fisher and Dornin, 2016). Due to the number of beds available for admission of acutely ill and injured patients continuing to fall over the past 5 years, the UK now has the lowest number of beds per capita in Europe, and England has the lowest number within the UK (Royal College of Emergency Medicine, 2016a). The consequence of limiting bed capacity has been a growth in general and acute bed occupancy from 86.3% in 2010–11, to 91.2% in 2015–16 (Royal College of Emergency Medicine, 2016b).

A lack of available beds reduces flow through A&Es as it slows the accommodation of new attendances (Royal College of Emergency Medicine, 2016a). This in turn affects the ability of ambulance services to off-load patients—an issue known as ‘congestive hospital failure’ (NHS England, 2013).

Another factor influencing occupancy rates is delayed transfer of care, which leaves systems less resilient to operational pressures. Unnecessary delay in discharging patients who no longer need to be in hospital led to 1.15 million bed days being lost in acute hospitals during 2015 (National Audit Office, 2016).

Combatting pressures

To help combat winter pressures, the NHS conducts strategic planning each year. For the 2017/18 winter, formal planning began at its earliest time yet in July (Philip, 2017). Local plans were submitted in September covering resilience arrangements from the start of December up to Easter 2018.

As part of this preparation, Public Health England (2017) publishes a Cold Weather Plan every year to help protect the population against harm from cold weather. A mixture of past experience and forward-planning will help build future resilience. Below are some of the key methods of combatting pressure.

Best use of ambulance services
An expansion of the ‘hear and treat’ and ‘see and treat’ services provided by ambulance services can help alleviate demand on A&E departments. ‘Hear and treat’ services refer to 999 calls that are successfully completed without dispatching an ambulance vehicle response. Examples of this include over-the-phone advice, instructions for self-care, or referral to other urgent services (Urgent and Emergency Care Review Programme Team, 2015).

‘See and treat’ services refer to a model of care where a patient is clinically assessed at scene, before being provided with immediate treatment and subsequent discharge and/or referral (Urgent and Emergency Care Review Programme Team, 2015). By avoiding taking patients unnecessarily to A&E, they can be referred to more appropriate services that better fit the patient’s needs, or further support can be provided at home or in a community setting. ‘Hear and treat’ and ‘see and treat’ services now cover 3.5 million people (NHS England, 2017b).

This winter will see the full rollout of phase two of the Ambulance Response Programme, with the introduction of new call standards that accurately reflect the type and urgency of care needed by patients (Quaile, 2017). Along with the new dispatch on disposition system, giving call handlers more time to triage 999 calls, it is hoped that many patients can avoid being taken unnecessarily to A&Es.

Boosting flu vaccinations
Flu outbreaks within health services can be crippling and are a genuine concern each winter. Last year, 49% of NHS staff were vaccinated against the influenza virus and, this year, the number of vaccinated staff has been raised to 63% (NHS England, 2017b).

Additionally, free flu jabs will be provided to hundreds of thousands of care-home staff at a cost of up to £10 million; and numbers of vaccinations for young children and vulnerable people will be increased (NHS England, 2017a). Being vaccinated is the best way to prevent the spread of flu infection and reduce avoidable deaths. As it is possible to have flu without showing any symptoms, health professionals could find themselves working with flu but not realising it. It is essential they are vaccinated to avoid spreading the illness to vulnerable people.

Increasing funding
The spring budget announced an additional £100 million to support improvements in emergency departments through the implementation of a primary-care streaming model (Philip, 2017). Here, patients are streamed away from highly pressured emergency departments, to co-located GP-led primary care services, for conditions more suited to assessment and treatment in primary care (NHS Improvement, 2017).

Achieving ‘good’ patient flow
According to Monitor (2015), improving patient flow through hospital departments other than A&E is ‘the most important systemic means’ of avoiding sharp declines in A&E performance during winter. Health systems that have better patient flow are much better at coping with external pressures than those who don’t (NHS Improvement, 2017). Within ambulance services, good patient flow is seen as the handing over of a patient to an emergency department within 15 minutes of arriving (NHS Improvement, 2017).

My Post (2)Encouraging self-care
Further promotion of self-care is essential to reducing demand on health services. Giving people the confidence and information to look after themselves can help prevent ill health and reduce pressure (British Medical Association, 2016). However, for this to work, support needs to be easily accessible.

Improving housing conditions
Housing conditions for vulnerable people play an important part in the number of excess winter deaths and illnesses. In the coldest 10% of homes, the death rate rises approximately 2.8% for every degree Celsius drop in the outside temperature (NICE, 2015).

In England, there is a relatively sharp increase in the risk of death when outdoor temperatures fall to around 6°C (NICE, 2015). Improving heating and insulation for vulnerable people is therefore highly important for reducing avoidable illness or death.

Addressing growing GP demand
General practice is on the brink of crisis as a result of inadequate resourcing, an insufficient workforce, and an unsustainable workload (British Medical Association, 2016). The number of GP consultations in England rose from 303 million in 2008/9 to 361 million in 2013/14 (Royal College of General Practitioners, 2015). However, despite this 19% increase in demand, there has been no change in resourcing and staffing, putting undue strain on GP services (British Medical Association, 2016).

Increased funding in social care
Social care has been struck by considerable funding cuts in recent years, creating a knock-on effect on the number of people receiving services.

There were 500 000 fewer people who accessed social care in 2013/14 compared to 2008/9 (Franklin, 2015). This is despite an increasing ageing population, where the number of over-85s will double over the next two decades. It is also anticipated that adults with a learning disability will increase by at least a third (Local Government Association, 2016).

The cut of £5 billion in local authority social care budgets over the last 5 years has placed significant pressure on services (Local Government Association, 2016). Delays in arranging community nursing or social care has a considerable impact on delayed transfers, with 60% of trusts believing the increase in delayed transfers of care is owing to reductions in social care capacity (Monitor, 2015).

Conclusion
This article has sought to explain the reasons behind additional pressures on health services brought on by the winter season. While attendances at A&E are lower during the winter, the number of hospital admissions of vulnerable patient groups rises, largely because of seasonal illnesses such as flu and norovirus. This causes a reduction in the number of beds available and reduced patient flow within hospitals.

To combat these pressures, longer term investments are needed to address the insufficient workforce, lack of social care, and demand on primary care services. Although there has been additional investment in vaccination against flu; primary-care streaming; and resilience funding for ambulance services for this winter; it is unclear what impact—if any—this will have on health services.

References

British Medical Association. Beating the effects of winter pressures: Briefing paper. 2016; London: BMA

Campbell D, Morris S, Marsh S. NHS faces ‘humanitarian crisis’ as demand rises, British Red Cross warns [Internet]. London: The Guardian; 2017. [cited 2017 Oct 23]. Available from http://tinyurl.com/y73vemzg

Department of Health, NHS England, NHS Improvement. Written evidence submitted by the Department of Health, NHS England and NHS Improvement (WIP0035) [Internet]. 2017. [cited 2017 Oct 23]. Available from http:// tinyurl.com/y7vlmu5r

Fisher E, Dorning H. Winter pressures: what’s going on behind the scenes? London: Quality Watch; 2016

Franklin B. The end of formal adult social care: A provocation by the ILC-UK. 2015; London: ILC-UK

House of Commons Health Committee. Winter pressure in accident and emergency departments: Third Report of Session 2016–17. 2016; London: The Stationery Office

Local Government Association. Adult social care funding: 2016 state of the nation report. 2016; London: LGC

Monitor. A&E delays: why did patients wait longer last winter? [Internet]. 2015. [cited 2017 Oct 23]. Available from http://tinyurl.com/ ofw2uv3

National Audit Office. Discharging older patients from hospital [Internet]. 2016. [cited 2017 Oct 23]. Available from http://tinyurl.com/hnyuy2p

National Institute for Health and Care Excellence. Excess winter deaths and illness and the health risks associated with cold homes. Clinical Guideline 6. 2015; London: NICE

NHS England. NHS leaders unveil action to boost flu vaccination and manage winter pressures. [Internet]. 2017a. [cited 2017 Oct 21]. Available from http://tinyurl.com/ycp5k8er

NHS England. The Handbook to the NHS Constitution. 2015; London: The Stationery Office

NHS England. Understanding Winter Pressures in A&E Departments [Internet]. 2013. [cited 2017 Oct 21]. Available from http://tinyurl.com/ yblaeduc

NHS England. Urgent and emergency care [Internet]. 2017b. [cited 2017 Oct 21]. Available from http://tinyurl.com/y9dctbsp

NHS Improvement. National priorities for acute hospitals 2017. Good practice guide: Focus on improving patient flow [Internet]. 2017. [cited 2017 Oct 23]. Available from http://tinyurl. com/y7t6mfam

Philip P. Letter to all CCGs and providers regarding planning for winter 2017/18, and other operational priorities [Internet]. 2017. [cited 2017 Oct 22]. Available from http:// tinyurl.com/y82kelxe

Public Health England. The Cold Weather Plan for England: Protecting health and reducing harm from cold weather. 2017; London: The Stationery Office

Quaile A. What’s next for England’s ambulance services? J Paramed Pract. 2017;9(10): 443-444

Royal College of Emergency Medicine. Why does winter in A&E get worse every year? 2016a; London: The Royal College of Emergency Medicine

Royal College of Emergency Medicine. Written evidence submitted on behalf of the Royal College of Emergency Medicine (WIP009) [Internet]. 2016b. [cited 2017 Oct 23].Available from http://tinyurl.com/y8naucxs

Royal College of General Practitioners. Patient safety implications of general practice workload. 2015; London: RCGP

Urgent and Emergency Care Review Programme Team. Transforming urgent and emergency care services in England: Clinical models for ambulance services. 2015; Leeds: NHS England

Taken from Journal of Paramedic Practice, published November 2017.

What’s next for England’s ambulance services?

Adobe Spark (7)Details of the delivery of new ambulance standards were outlined by the National Clinical Director for Urgent Care at the Health and Care Innovation Expo in Manchester (NHS England, 2017a). Professor Jonathan Benger provided delegates with an overview of the Ambulance Response Programme, which he called: ‘the way we should do change in the NHS—change that is evidence based from the very beginning.’

Outlining the programme

The implementation of the Ambulance Response Programme was announced by NHS England (2017b) in July, following recommendations by the NHS England National Medical Director, Professor Sir Bruce Keogh, to the Health Secretary (Keogh, 2017). It consists of three initiatives that were developed to try and improve clinical responses for patients.

Phase 1 involved changes to the triage of calls to allow more time for call handlers in cases that are not deemed as immediately life-threatening. This has been referred to as dispatch on disposition. Traditionally, handlers had up to 60 seconds to assess calls and establish the urgency of the problem, and the type of response required. It is at this point that the clock is started for the performance measurement. The subsequent issue was that in an effort to meet an 8-minute response standard, ambulance services were sending multiple vehicles to the same patient and standing down the vehicles they thought wouldn’t get there first. Response cars would frequently be used as a way of ‘stopping the clock’ but then the patient would have a long wait for the transporting ambulance, which was detrimental to the patient but not measured on the system. According to Benger:

‘The problem created was one whereby a paramedic in a response car might spend their entire day just driving from one call to another but never actually reaching a patient.’

The Ambulance Response Programme therefore sought to provide a more clinically appropriate response by targeting the right resource to the right patient. For non-life-threatening calls, ambulance call handlers were given up to an additional 3 minutes to determine what was wrong with the patient and therefore decide an appropriate response.

Phase 2 involved the introduction of a new code set that has four key categories, rather than two, which better reflects the wide range of needs patients have when they dial 999. In the old system almost 50% of calls to ambulance services are classified as Red 1 or Red 2, requiring a response within 8 minutes. However, this does not accurately reflect the type and urgency of care needed by patients (Turner et al, 2017). Under the new system there will now be four revised call categories:

  • Category 1 is for life-threatening calls. These are for people needing treatment for life-threatening illnesses or injuries and will be responded to in an average of 7 minutes
  • Category 2 is for emergency calls. These are potentially serious conditions that may require rapid assessment, urgent on-scene intervention and/or urgent transport. These will be responded to in an average of 18 minutes
  • Category 3 is for urgent calls. These are non-life-threatening problems involving patients needing treatment to relieve suffering. Often they can be managed at the scene and 90% of these patients will be responded to within 120 minutes
  • Category 4 is for less urgent calls. These are for non-urgent problems requiring assessment either face-to-face or by telephone and 90% of these patients will be responded to within 180 minutes.

The final initiative involved a review of the current ambulance system, Ambulance Quality Indicators (AQI), and the development of a revised set of indicators linked to the revised call categories.

Evaluating the programme

A formal trial of Phase 1 began in October 2015 and a trial of the Phase 2 revised call categories began in three services in April 2016. An evaluation of Phases 1 and 2 was published by researchers at Sheffield University (Turner et al, 2017). Benger said:

‘We are very fortunate in the Ambulance Response Programme to have very good stakeholder engagement and excellent independent academic scrutiny from Sheffield University.

‘They have analysed the data we’ve collected from more than 14 million 999 calls. Of those 14 million patients, no patient came to harm as a result of the Ambulance Response Programme.’

The review revealed that under the new dispatch on disposition system, early recognition of life-threatening conditions, such as cardiac arrest, will increase. The knock-on effect is up to an additional 250 lives saved each year. By sending an appropriate response, more vehicles will be freed up to attend emergencies, and patients will be conveyed to the appropriate place.

According to Benger, when call handlers were given more time, rather than impeding or reducing the speed of response for the sickest patients, speed and performance actually improved.

‘The ambulance services became a lot more efficient,’ said Benger. ‘Taking the entirety of both dispatch on disposition and the new coding set together, we were releasing 15 000–16 000 additional resources each week that could respond to a 999 call, when that was not previously the case. And that’s principally from putting an end to duplicate responses.’

Evaluation of Phase 2 on its own, however, is more complicated. The use of time-based standards as a key performance measure have been used by ambulance services throughout the world, despite a lack of evidence that they actually lead to good clinical care. As Phase 2 has only been operational for a short period of time, it is not possible to say whether the new model is better, only that it is ‘different’ (Turner et al, 2017). However, the three services reviewed indicated a period of operational stability during a period of high demand, even when response time performance continued to deteriorate in services operating the current national model.

It is thought that the more flexible approach to call assessment, resource dispatch, and response intervals brought on by the combination of dispatch on disposition and the
new code set, may reduce further deterioration in performance and maintain a consistent service. However, as highlighted by the researchers at Sheffield University, a system of ongoing review and refinement is needed to optimise delivery (Turner et al, 2017).

Implementing the programme

All ambulance services are now using dispatch on disposition, and the new call categories are intended to be fully implemented by winter 2017. This will hopefully reduce pressures on A&Es during their busiest time period.

‘We wanted to make ambulance services as efficient as they could be but that we didn’t lose sight of some of the core aims: prioritising the sickest patients, making sure we incentivise clinically and operationally efficient behaviours, and trying to reduce the long waits for patients,’ said Benger.

‘When I first started in my job, I noticed that when you gathered ambulance chief executives together in a room, they would spend about 90% of the time talking about ambulance response times and 10% about clinical outcomes. I’d like to reverse that.’

As demand for urgent and emergency care sees year-on-year increases, services have to adapt to reduce pressure and ensure patients are able to get the care they need. It is hoped the new ambulance standards will go some way to making this a reality.

References

Keogh B. Ambulance Response Programme—letter to Secretary of State [Internet]. Leeds: NHS England; 2017. Available from http://tinyurl.com/ybfgxmfx

NHS England. What next for England’s ambulance services? Leeds: NHS England; 2017a. Available from http://tinyurl.com/yb7vzk8g

NHS England. New ambulance standards announced. Leeds: NHS England; 2017b. Available from http://tinyurl.com/yc6ywmqs

Turner J, Jacques R, Crum A, Coster J, Stone T, Nicholl J. Ambulance Response Programme: Evaluation of Phase 1 and Phase 2. Final Report. Sheffield: School of Health and Related Research, University of Sheffield; 2017.

Taken from Journal of Paramedic Practice, published October 2017.