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.

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More advanced paramedics needed if A&E pressure is to be eased

Adobe Spark (1)The NHS must introduce more advanced paramedics if emergency departments are to meet growing patient demand. The NHS is reaching a crisis point—annual rises in emergency admissions and insufficient resources mean patients aren’t receiving the necessary levels of care. Traditionally, care provided by paramedics has focused on the immediate assessment and management of potentially life-threatening emergencies. This is then followed by transfer to an appropriate receiving unit. However, increasingly, evidence suggests that patients who present to ambulance services with lower acuity presentations could alleviate the need for hospital admission by undergoing assessment and management in the community.

This is highlighted in new draft guidance published by NICE (2017), which should fall on welcome ears to ambulance services. It recommends that the NHS provides more advanced paramedic practitioners (APPs), who have extended training in assessing and treating people with medical emergencies, to relieve pressure on emergency departments.

Evaluating the evidence

In order to make these recommendations, the guideline committee investigated whether enhancing the competencies of paramedics resulted in a reduction in hospital admissions and demand for emergency department services. When considering clinical evidence, three studies were included in the review. Two studies, which came from the same cluster-randomised controlled trial, looked at a paramedic practitioner service in the UK, which gave enhanced training to paramedics.

The first study comprised 3018 people and evaluated the benefits of paramedic practitioners who have been trained with extended skills to assess, treat, and discharge older patients with minor acute conditions in the community (Mason et al. 2007). The evidence suggested that enhanced competencies of paramedics may provide benefit for reducing the number of hospital admissions (0–28 days), emergency department attendance (0–28 days), and patient and/or carer satisfaction. There was no effect on mortality.

The second study comprised 2025 people and evaluated the safety of clinical decisions made by paramedic practitioners of older patients contacting the emergency medical services with a minor injury or illness (Mason et al. 2008). Of the 3018 patients recruited into the randomised-controlled trial, 993 were admitted to the hospital at the index episode, which explains why they were excluded from the analysis in this study. The evidence suggested that there was no effect of paramedics’ enhanced competencies on unplanned emergency department attendance.

The final study was a non-randomised (quasi-experimental) study of emergency care practitioners who worked as single responders to ambulance service 999 calls, compared with standard paramedic or technician ambulance responding to ambulance service 999 calls. The study comprised 1107 people and aimed to evaluate the impact of emergency care practitioners on patient pathways and care indifferent emergency care settings.
(Mason et al. 2012). The evidence suggested that enhanced competencies of paramedics may provide a benefit from reduced numbers of patients referred to hospital (emergency department or direct admission to a hospital ward), and increased number referred to primary care.

Additionally, one cost-utility analysis was assessed to consider the economic implications of providing additional advanced paramedics within ambulance services, and found that the paramedic practitioner scheme was cost-effective compared with the standard 999 service (Dixon et al. 2009). This study was assessed as partially applicable with minor limitations.

Points for concern

There are a number of considerations when looking at the evidence in question that could be cause for concern. While evidence exists, it is minimal, with only one
randomised-controlled trial and one non-randomised study evaluated by NICE. Though results from the studies are positive, it would be difficult to generalise them beyond the services assessed. Additionally, the quality of evidence is generally of a low GRADE (Grading of Recommendations, Assessment, Development and Evaluations). The randomised-controlled trial evidence has a moderate-to-low GRADE rating overall, mainly owing to risk of bias and imprecision (NICE 2017). The non-randomised study, although it had large effect sizes, has a very low GRADE rating as a result of high risk of bias and indirectness of the outcomes to the protocol (NICE 2017). The economic evidence was considered high-quality but only partially applicable because the costs were quite dated. Some social care costs were also included, which means that the perspective is not strictly NHS and personal social services (NICE 2017).

There are notable concerns over the definition of an APP, as there is a national lack of consensus over paramedic roles and scope of practice. This was a contributing factor to why independent prescribing by APPs was not recommended by the CHM and MHRA (Allied Health Professions Medicines Project Team 2016).

The need for unanimity across all ambulance services is a concern the College of Paramedics emphasised inits response to the guidance:

‘There has previously been insufficient attention given to career development and career opportunities and there is currently significant variation across the ambulance services in the definitions, titles, education, and training of specialist and advanced paramedics. To ensure consistency of education, training and qualification, the UK ambulance services would need to adopt the frameworks developed by the College of Paramedics, which provide detailed guidance on education, competencies, and career development’ (College of Paramedics 2017).

The College of Paramedics has a clear definition of the APP role in terms of competencies and education:

‘Advanced paramedics are experienced autonomous paramedics who have undertaken further study and skill acquisition to enable them to be able to deliver a more appropriate level of assessment and indeed care to patients in the community and access many more referral pathways.’

It is essential that this becomes the accepted definition across the NHS, and the private health sector. This will ensure that all advanced paramedics are clinically competent and that patient safety is not at risk. More advanced paramedic practitioners with extended training could alleviate current pressures on A&E services.

From guidance to practice

Consulting on the guidance closed on 14 August, with an expected publication of 20 December. If the guidance is to be put into practice, the most important step is to introduce additional funding for NHS ambulance services to educate their clinicians through advanced practice programmes. NHS England and clinical commissioning groups would then have to provide funding to deliver specialist and advanced paramedics as part of the core workforce. Additionally, regulation is essential to ensure clinical competency and patient safety.

There is no denying that acute and emergency care is a challenge for all health services. This is largely owing to the fact that as populations age, costs rise, and technological developments extend the limits of health care. However, providing acute and medical care in the community can reduce the need for hospital admissions.

The introduction of more advanced paramedics will meet the increasing and changing needs of patients who access 999 emergency ambulance services. Having a higher proportion of emergency patients assessed and treated in the community will cause a reduction in the number of attendances at emergency departments.

References

Allied Health Professions Medicines Project Team. 2016. Summary of the responses to the public consultation on proposals to introduce independent prescribing by paramedics across the United Kingdom. Leeds: NHS England.

College of Paramedics. 2017. College of Paramedics respond to NICE Consultation [Internet]. Bridgwater: College of Paramedics; [cited 2017 29 August]. Available from https://www.collegeofparamedics.co.uk/news/college-of-paramedics-responds-tonice-consultation.

Dixon S, Mason S, Knowles E. 2009. Is it cost effective to introduce paramedic practitioners for older people to the ambulance service? Results of a cluster randomised controlled trial. Emerg Med J. 26(6):446-51. http://doi.org/ 10.1136/emj.2008.061424.

Mason S, Knowles E, Colwell B et al. 2007. Effectiveness of paramedic practitioners in attending 999 calls from elderly people in the community: cluster randomised controlled trial. BMJ. 335(7626):919. http://doi.org/10.1136/bmj.39343.649097.55

Mason S, Knowles E, Freeman J, Snooks H. 2008. Safety of paramedics with extended skills. Acad Emerg Med. 15(7):607–12. http://doi.org/10.1111/j.1553-2712.2008.00156.x.

Mason S, O’Keeffe C, Knowles E. 2012. A pragmatic quasi-experimental multi-site community intervention trial evaluating the impact of Emergency Care Practitioners in different UK health settings on patient pathways (NEECaP Trial). Emerg MedJ. 29(1):47-53. http://doi.org/10.1136/emj.2010.103572.

National Institute for Health and CareExcellence. 2017. Emergency and acute medical care in over 16s: service delivery and organisation: Draft guidance consultation [GID-CGWAVE0734] [Internet]. London: NICE; [cited 2017 29 August]. Available from https://www.nice.org.uk/guidance/indevelopment/gid-cgwave0734/consultation/html-content.

Taken from Journal of Paramedic Practice, published 8 September 2017.

Passing the mantle: a parting farewell

Adobe SparkThis issue of the Journal of Paramedic Practice will be my last as editor. It has been an honour and privilege to edit a publication aimed at one of the most exciting healthcare professions, and I am grateful for being given this fantastic opportunity. I took over the journal in 2013, having previously worked on a nursing title, and in those few short years have witnessed a notable change within the paramedic profession.

The publication of the Francis report marked the beginning of my time as editor, and although not directly concerned with paramedics, it highlighted a need for cultural change within the NHS, with an emphasis on patient-focused care. This was followed by the long overdue update to the UK Ambulance Services Clinical Practice Guidelines, which was welcomed by the profession. The latest update was published earlier this year.

The publication of the end of study report for the Paramedic Evidence Based Project (PEEP), which called for the introduction of a national education and training framework for paramedics, marked a turning point for the profession and highlighted how its needs were changing. This was cemented in Sir Bruce Keogh’s Urgent and Emergency Care Review, which called for the development of 999 ambulance services so that they become mobile urgent treatment services. Illustrating an appreciation of the skill set of paramedics, their potential in the delivery of pre-hospital care was finally being recognised.

The Five Year Forward View expanded on these ideas and proposed a broadened role for ambulance services. It was becoming apparent that out-of-hospital care was becoming an increasingly important part of the work the NHS undertakes.

One of the most significant changes within the profession over the last few years has been the growth of its professional body. As of January 2016 there were 6 458 full members of the College of Paramedics. This represents 29.7% of all paramedic registrants of the Health and Care Professions Council, the regulatory body for the paramedic profession. The increase in members show the College is one step closer to its aim of becoming a Royal College, which requires that 50% of the profession are members of the professional body.

However, this evolution has not been without its difficulties. Reports of staff facing burnout, time taken off work due to stress-related illnesses, problems with staff retention, disputes over pay, and the fundamental problem of how ambulance services can cope with year-on-year increases in demand, mean the workforce is facing all manner of pressures.

Despite this, I believe these are exciting times for paramedics. As we gradually see a move to an all-graduate profession and changes to the paramedic scope of practice, the opportunities for work outside of the ambulance service are growing.

As I pass the mantle, I look forward to seeing the journal reach new heights following my departure under a new editor. It only remains for me to personally thank my consultant editors, the editorial board, and of course, you the readers, who have ensured the publication could continue.

Taken from Journal of Paramedic Practice, published 5 August 2016.

Pay survey reveals two thirds of paramedics considering leaving ambulance service

Adobe Spark (5)Two thirds of staff say they will consider leaving the ambulance service if a change to the pay banding of paramedics is not made, according to a survey carried out by the Journal of Paramedic Practice.

An online poll completed by 1084 paramedics has revealed that 67% will consider leaving the ambulance service if the Government continues to fall back on its 2015 promise of reviewing the banding system to recognise the skill set of paramedics. Additionally, 87% felt the Government has misled ambulance service staff over promises for pay.

One respondent said: ‘Increased pressure to use alternative pathways, treat at home, discharge on scene. Increased level of assessment and treatment options, together with increased expectation of qualifications and study, but for no extra pay? Ridiculous.’

Another said: ‘Several of my colleagues and friends are struggling to pay their home bills and have left the job for better paying roles in the Arab states.’

Commenting on the findings, Gerry Egan, chief executive officer for the College of Paramedics, said:

‘Since its establishment, the College of Paramedics has worked hard to develop the paramedic profession in the interests of providing the best possible care to patients and to ensure that paramedics receive due recognition for the service they give to society.

‘This combined with the increased reliance on paramedics by the health system, which has come about for a number of reasons, means that there has been a continuous increase in the expectations of the range and quality of services that paramedics provide. So it comes as no surprise that the results of the Journal of Paramedic Practice’s survey are similar to a survey conducted by the College of Paramedics last year.

In 2014, paramedics were among the thousands of health professionals who took to the picket line in the first NHS strike over pay in 32 years.

The dispute came as ministers in England awarded NHS staff a 1% increase in pay, but only for those without automatic progression-in-the-job rises.

Despite the independent NHS Pay Review Body recommending a 1% rise across all pay scales, ministers claimed this was an ‘unaffordable’ cost.

In a desperate effort to resolve the pay dispute of 2014/15, the Secretary of State for Health, Jeremy Hunt, agreed to a number of commitments to ambulance staff, including a review of the banding system.

Current vacancy rates for the paramedic profession are at 10%. This represents 1 250 vacancies out of a total workforce of 12 500. It is believed that these high vacancy rates are due to changes made to the healthcare system in recent years. This includes a shift in focus to treat patients at home rather than conveying them to A&E, as well as a change in the nature and volume of job opportunities for paramedics.

Almost all respondents (93%) of the survey believed that the current scope of practice of paramedics is changing as a result of increased skills and competencies. Additionally, 94% felt band 6 of the Agenda for Change pay scale was a more appropriate pay band due to the level of responsibility and autonomy practised within the paramedic role, including triage, referrals, and decisions around non conveyance. Overall, 96% believed their pay did not reflect their responsibilities.

However, not all believed that current pay for paramedics has contributed to increasing vacancy rates and the number of people leaving the profession.

‘I disagree that this would be a reason for paramedics leaving,’ said one respondent. ‘With the role having changed so much, I believe that our advanced practice colleagues (paramedic practitioner/emergency care practitioner) are leaving to work in hospitals. There is potential to earn more money, better chance of a break, and better working conditions. I disagree that pay alone is a reason staff are leaving.’

According to Egan, the significance behind the figures for those considering leaving the profession may be unclear:

‘The responses regarding those intending to leave their positions as paramedics may be blurred somewhat between those intending to leave ambulance service employers and those who might leave the profession,’ he said. ‘It is a well-known fact that many paramedics are leaving ambulance services to take up opportunities in walk-in centres, minor injuries units and the like.’

A large number of respondents felt that it was work pressures and stress that have contributed most to the number of paramedics leaving the ambulance service:

One respondent said: ‘I don’t think pay is a factor in staff leaving. Lack of retention [is] more likely due to increased workloads, poor culture and public expectation.’

Another respondent said: ‘There have been some paramedics with MSc or BSc that have left to find better paid jobs. But the majority of paramedics leaving the profession is due to the increasing workload and the undertaking of urgent care alongside emergency work. Demand, stress and pressure are why paramedics are leaving, not money.’

Stress and burnout remain an undeniable issue facing ambulance staff, with paramedics in England taking 41 243 days off in 2014 as a result of stress-related illnesses. This has had an inevitable impact on those choosing to leave the ambulance service. Only a handful of ambulance services have agreed to pay paramedics Agenda for Change band 6 in the hope of recruiting and retaining paramedics .

Another significant finding was that 66% of respondents believed there are no adequate opportunities for career progression.

A common consensus was that progression only came in the form of management positions, with few opportunities for promotion in a clinical capacity.

One respondent said: ‘There are a number of areas within the paramedic profession to progress to, such as critical care roles or minor health roles, or management; however, these areas still do not have the same pay scale as other health sectors, meaning progression, while increasing skills, does not increase pay, therefore [it] is seen as a way to gain skills in order to leave to a sector with increased pay.’

However, this was not felt by all, with one respondent highlighting the work that the College of Paramedics has done to outline career pathways:

‘The College of Paramedics (and South East Coast Ambulance NHS Foundation Trust) has done a lot to develop career pathways. Integration of the out-of-hours providers and the ambulance service would provide even more opportunity for paramedics to progress as well as improving the response times for patients.’

Commenting on the suggestion there are insufficient career progression opportunities within the paramedic profession, Egan said: ‘The College would argue that its career framework sets out the roadmap for career progression and the shortage of opportunities may be a problem to be addressed by the main employers of paramedics.’

As a result of the Government not reviewing the banding system for paramedics, the unions UNISON, GMB and Unite conducted consultative ballots of ambulance staff. The responses indicated that ambulance staff in England will take part in industrial action, including strike action, if the Government continues to not deliver in its promises over pay.

Each union is reporting their ballot results to members, before consulting over the next steps.

Results published by Unite show that 66% of members voted yes to taking strike action and action short of strike action, with a turnout of 31%.

Results from the other two unions have not yet been made public.

A joint statement issued by the unions said:

‘We are clear that ambulance staff have waited for 12 months and are not going to wait longer. If possible, we would also like to avoid a dispute, and the disruption that strike action will bring, however we know that ambulance staff are not prepared to wait indefinitely.

‘We will be calling on Government to make real commitments to ambulance staff, within clear timescales. If there is a genuine will to avert a dispute then we will pause the move to a full industrial action ballot while we hold constructive discussions.’

While the National Ambulance Strategic Partnership Forum have made a formal request to the National Job Evaluation Group to look at the National Job Evaluation paramedic profile, only a handful of ambulance services have agreed to pay paramedics Agenda for Change band 6 in the hope of recruiting and retaining paramedics. This includes East of England Ambulance Service NHS Trust, West Midlands Ambulance Service NHS Foundation Trust, Yorkshire Ambulance Service NHS Trust. There is currently no indication that other services will follow suit.

Taken from Journal of Paramedic Practice, published 1 July 2016.

Working together to improve efficiencies

Adobe Spark (4)It was recently announced that the North East Ambulance Service NHS Foundation Trust, North West Ambulance Service NHS Trust and Yorkshire Ambulance Service NHS Trust will be coming together to form an alliance across the North of England (Association of Ambulance Chief Executives (AACE), 2016). The services have said the launch of the Northern Ambulance Alliance will help to improve the efficiency of ambulance services in the areas covered by all three Trusts.

It is important to stress that it is not a merger but an attempt by all three organisations to work closer together to improve patient care. Additionally, it is felt the alliance should help identify savings through collaborative procurement and offer improved resilience. So, in effect, the boards of each of the individual Trusts will still have responsibility for their individual service, but will also consider the work and objectives of the Northern Ambulance Alliance when making decisions.

One of the key driving forces behind the inception of the alliance was the Lord Carter Review (2015)into productivity in NHS hospitals, which supports identification of efficiencies and reduction of unwarranted variances. Some of the areas already identified where the Trusts can work together include looking at ‘efficiency through joint procurement exercises, major changes to IT, assessing specialist expertise and learning from each other’s achievements’ (AACE, 2016).

This alliance should be commended and highlights the overall commitment from each of the Trust’s to improve patient care. While demand for each service will inevitably differ due to considerations such as population and community, their strategic priorities are inextricably linked. It therefore makes sense that they should be considered together. More than anything, the alliance offers an excellent opportunity for the sharing of best practice and to tackle mutual difficulties. An example was highlighted by Rod Barnes, chief executive officer of Yorkshire Ambulance Service NHS Trust, of how the Trusts could come together to deliver on a single issue: ‘This might mean the procurement of a single agreed vehicle specification for all three services, identifying savings through the standardisation of maintenance and equipment contracts, which is something that has proved elusive at a national level’ (AACE, 2016).

It has been assured that there will be no direct staff consequences as a result of the alliance. However, it may mean in the future that the three organisations consider joint appointments or shared working for new roles and replacements.

It is hoped that other services will follow and create their own alliances. Who knows, it may even be one step closer to a single national ambulance service.

References

Association of Ambulance Chief Executives (2016) Three Northern Ambulance Trusts Form Alliance “That Will Improve Efficiencies”. http://aace.org.uk/ambulance-alliance-will-improve-efficiencies/ (accessed 27 June 2016)

Carter PR (2015) Operational productivity and performance in English NHS acute hospitals: Unwarranted variations. An independent report for the Department of Health by Lord Carter of Coles. The Stationery Office, London

Taken from Journal of Paramedic Practice, published 1 July 2016.

Ambulance service at creaking point

Adobe SparkRecent figures published by NHS England reveal the ambulance service is continuing to fail to meet Government standards for responding to Category A (Red 1 and Red 2) calls. The figures for March 2016 showed only 66.5% of Red 1 calls were responded to within 8 minutes, while 72.3% of Red 2 calls received a response within the same timeframe (NHS England, 2016). This is compared to 73.4% and 69.6%, respectively for the same period in 2015. It marks 10 months that services in England as a whole have failed to meet the Government target of 75% for Red 1 Calls. The response to Red 2 calls is the lowest proportion recorded since the data collection began in June 2012. However, it must be highlighted that Red 2 data from February 2015 onwards are not completely comparable across England due to the introduction of Dispatch on Disposition, allowing up to two additional minutes for triage to identify the clinical situation and take appropriate action.

It has been a tough year for ambulance services, with London Ambulance Service NHS Trust being placed under special measures by the Care Quality Commission (CQC) in November 2015 and East Midlands Ambulance Service NHS Trust being recently rated inadequate by the CQC for safety due to insufficient staff numbers and a consensus that the skill mix of staff deployed was not always safe (CQC, 2016).

The fact of the matter is that demand for ambulance services continues to rise and services are struggling to keep up. The ambulance service in England received 861 853 phone calls in March 2016, compared to 694 188 in March 2015 (NHS England, 2015; 2016), a rise of 24%. However, Trusts have not been able to increase their numbers of staff to meet this demand. This creates greater work pressures and stress for existing employees, brought on by longer working hours and missed meal breaks. The result? High staff attrition within Trusts. Those that remain will no doubt be questioning whether this is sustainable. With staff currently being balloted by unions over industrial action on pay, the possibility of a crisis within the ambulance service cannot be dismissed as hearsay.

If this is to be avoided, a number of things have to change. Trusts must ensure front-line vacancies are filled and staff do not leave. This can only be done by fostering a work environment in which staff are happy to remain. The over triage of patients must be minimised so that appropriate resources are dispatched. And, where possible, patients’ needs must be addressed at the point of contact and unnecessary transfers to hospital must be avoided. If the ambulance service carries on as it is, it is difficult to see how it will continue to operate in 10 years’ time. By focusing on employee welfare, this crisis may be averted.

References

Care Quality Commission (2015) London Ambulance Service NHS Trust Quality Report, 27 November 2015. http://tinyurl.com/hxdhwpr (accessed 26 May 2016)

Care Quality Commission (2016) East Midlands Ambulance Service NHS Trust Quality Report, 10 May 2016. http://tinyurl.com/h5r4wfv (accessed 26 May 2016)

NHS England (2015) Ambulance Quality Indicators Data 2014–15. http://tinyurl.com/zf2p5jf (accessed 26 May 2016)

NHS England (2016) Ambulance Quality Indicators Data 2015–16. http://tinyurl.com/jyls6rt (accessed 26 May 2016)

Taken from Journal of Paramedic Practice, published 27 May 2016.

Ambulance service contributed to loss of lives at Hillsborough disaster

Adobe Spark (2)Following the longest inquest in British legal history, the jury of the Hillsborough disaster that occurred at the 1989 FA Cup semi-final between Liverpool and Nottingham Forest, ruled that lives were lost as a result of mistakes made by the ambulance service.

The disaster, which saw 96 Liverpool fans die and 766 injured, occurred after police opened an exit gate to alleviate the throng of people outside. This lead to a huge influx of supporters into two of the pens, causing severe crushing to those fans already in the terrace.

After hearing evidence for over 2 years, the jury of six women and three men reached a verdict of unlawful killing by a 7-2 majority.

They were asked 14 questions related to areas such as basic facts of the disaster, policing, behaviour of the supporters and defects in the Hillsborough stadium.

When questioned on the emergency response and the role of the South Yorkshire Metropolitan Ambulance Service (SYMAS) after the crush in the west terrace had begun to develop, it was agreed that error or omission on behalf of SYMAS contributed to the loss of lives in the disaster.

In particular, it was felt that SYMAS officers at the scene failed to ascertain the nature of the problem at Leppings Lane, and the failure to recognise and call a Major Incident led to delays in responses to the emergency.

Speaking after the ruling, Rod Barnes, Chief Executive of Yorkshire Ambulance Service NHS Trust, extended his sympathies to the bereaved families of those who lost their lives as a result of the tragedy.

‘We fully accept the jury’s conclusions that after the crush began to develop there were mistakes made by the ambulance service,’ said Barnes. ‘Lives could have been saved on the 15th April 1989 had the emergency response been different.’

He went on to apologise on behalf of Yorkshire Ambulance Service: ‘I am truly sorry. Our thoughts remain with the families as they continue to grieve and come to terms with the evidence they have heard over the last 2 years.’

‘As one of the successor organisations of South Yorkshire Metropolitan Ambulance Service, we have had a responsibility to ensure a full and fair examination of their response. We have done our best to make sure all relevant evidence about the ambulance service response has been put before the Court, placed in context and properly explored in an open way,’ he added.

He highlighted how the ambulance service has changed in the last 27 years and stressed how a lot has been learned from Hillsborough and other incidents.

‘We, as an organisation, are not complacent. I would like to reassure the public that the ambulance service’s ability to respond to a major disaster such as this has changed beyond all recognition.

‘We understand the importance of today for the families and friends of those who died. Our thoughts remain with them.’

In addition to the ambulance service, it was concluded that the South Yorkshire police were responsible for the development of the dangerous situation and subsequently contributed to the loss of lives due to a lack of coordination, communication, command and control, which in turn delayed or prevented appropriate responses.

The Prime Minister, David Cameron, said that the jury’s ruling of the Hillsborough inquests has provided ‘official confirmation’ that Liverpool fans were ‘utterly blameless in the disaster’.