The need for optimism at a challenging time for the NHS emerges as key theme of Ambulance Leadership Forum

The Association of Ambulance Chief Executives’ (AACE) annual Ambulance Leadership Forum (ALF) took place this year on 9–10 February at the Hinckley Island Hotel in Leicestershire. Designed to stimulate debate and ideas about the on-going development of emergency and urgent care, delegates were encouraged to share best practice and discuss issues pertinent to the sector.

The theme for this year’s event focused around the future look and feel of ambulance service provision and was largely based on AACEs document published last year, A vision for the ambulance service: 2020 and beyond. This vision presents ambulance services as mobile healthcare providers operated in an extended range of care settings, doing more diagnostic work, more treatment, more health promotion, and providing patients with more services that before.

Delegates were welcomed to the conference by AACE chair and West Midlands Ambulance Service NHS Trust CEO, Anthony Marsh, who called on attendees to embrace the new ambulance initiatives on offer and improve outcomes. He noted that ‘the challenge we are confronted with now [in the NHS] offers us a real opportunity,’ and hoped proceedings for the day would help influence national policy.

The landscape of urgent and emergency care: implementing the Five Year Forward View

The opening address was given by Chris Hopson, CEO of NHS Providers, who asked whether the provider sector had the capacity to deliver the changes outlined in NHS England’s Five Year Forward View? Hopson said that all Trusts would be under pressure to achieve their financial targets in 2016–2017 and that one of the biggest debates would be over standards and performance, especially for ambulances. He highlighted that the majority of providers have found themselves in the ‘needs improvement’ box in terms of Care Quality Commission rating, and that we cannot fix many problems found in the NHS unless we have more vertical integration of health and care and horizontal collaboration.

Prof Keith Willett, national director for acute episodes of care for NHS England, then spoke on the new landscape for urgent and emergency care. He started by mentioning he sat on a sharp fence between the clinical world of service providers and Whitehall, and noted it is a sharp fence. The current provision of urgent and emergency care services sees 24 million calls to the NHS and 7 million emergency ambulance journeys a year. Willett said for those people with urgent but non-life threatening needs we must provide ‘highly responsive, effective and personalised services outside of hospital, and deliver care in or as close to people’s homes as possible.’ For those people with more serious or life-threatening emergency needs, he said: ‘We should ensure they are treated in centres with the very best expertise and facilities in order to maximise their chances of survival and a good recovery.’ As we move into the final phase of the Urgent and Emergency Care Review, the focus is on implementing new models of care and ways of working. He stressed that the ambulance service needs to come to the fore and drive change, and that no paramedic should make a decision in isolation, but should have support from whole of the NHS.

Transforming health and social care: innovation and leadership

Following the first coffee break of the day, Bob Williams, CEO of North West Ambulance Service NHS Trust, spoke on devolution in Manchester. After providing a background to the health and social care system in Greater Manchester and the Greater Manchester Devolution Agreement, Williams outlined the principles around the Greater Manchester devolution plan, which include: radical upgrade in population health prevention, transforming care in localities, standardising acute hospital care, and standardising clinical support and back office services. Williams said Greater Manchester devolution offers an opportunity to transform health and social care, and that ambulance service has the tools, the players and the crucial elements to help make the healthcare system changes needed.

Prof Paresh Wankhade of Edge Hill University then spoke on leadership in the emergency services, focusing on interoperability and innovation. Wankhade first set the scene by outlining the leadership challenges faced by emergency services, before highlighting the key issues impacting workforce development, the need for suitable leadership for empowering and motivating staff, provided a critical overview of the state of interoperability, and closed by speaking about innovation in an era of uncertainty. For the ambulance service, he noted an increasing demand but lesser proportion of life-threatening calls, and that performance and quality are unsustainable with current levels of funding. He went on to say that there is very little evidence to suggest that enough is being done to support the workforce for new challenges and performance pressures, and that there is an important role for the College of Paramedics to prepare practitioners for the future.

Leading in challenging times

After lunch, delegates heard a recorded message from Lord Prior of Brampton, parliamentary under secretary of state for NHS productivity, who commended the work that is being done by ambulance services across the country, and apologised on behalf of the secretary of state for health, Jeremy Hunt, who had to pull out the conference last minute.
This was followed by Rob Webster, CEO of NHS Confederation, who gave one of the most engaging talks of the day on leading in challenging times. He began by explaining there has been a 24% increase in activity for Category A calls for ambulance services since 2011. He went on to stress the need for values-based leadership and system leadership, and that leading should come from every seat in the NHS. If senior ambulance managers do not understand the organisation’s values, then it is difficult to expect staff to understand them. He closed by noting that the NHS is made of people, and that it is the collective commitment, drive and energy that make up an organisation, and what makes a successful future.

Janette Turner, director of the medical research unit at the University of Sheffield, then spoke on managing urgent care outside hospital. Looking at data from March 2015, 27.9–57.6% of 999 calls were not conveyed to emergency departments in England. On population utilisation of emergency ambulance services the UK receives 13 calls per 100 population, compared to Belgium, which has the highest number of calls per population in Europe at 33. Turner said that outcomes of evidence on telephone-based service involved accuracy, compliance, satisfaction, costs, service impact and access. While accuracy is high for minimising risk, inaccuracy tends to come in the form of over triage. Considering the role of management by ambulance clinicians outside hospital, Turner said a small number of high-quality studies support extended paramedic roles as they offer safe decisions, reduced emergency department transports, high satisfaction and are cost effective. However, she did note that decision-making is complex and needs to be underpinned by the right education.

Introducing new delivery models

After another coffee break, Richard Murray, director of policy at the King’s Fund, spoke on new delivery models for urgent and emergency care and NHS Planning Guidance. Murray outlined the key features of NHS Planning Guidance before discussing the implications for urgent and emergency care and ambulance providers. He said it was a game of two halves: a one-year plan for 2016/17, with existing organisations as the key building block, switching to place-based plans for 2017/2018 to 2020/2021. Taken together, Murray said they offer a radical re-drawing of the boundaries in the NHS.

The final talk of the day was delivered by Dr Phil Foster, assistant medical director for Yorkshire Ambulance Service NHS Trust, who spoke on the West Yorkshire Urgent and Emergency Care Vanguard. He explained how the service’s collective local vision was for all patients with emergency and urgent care needs within West Yorkshire to get ‘the right care in the right place—first time—every time.’ The aim was to give patients access to urgent and emergency care through 999 and 111 and given an improved experience with care provided closer to home. This would be a standard service offering across West Yorkshire.

Celebrating excellence at the AACE Outstanding Service Awards

The evening saw delegates celebrate the AACE Outstanding Service Awards. Sponsored by Ferno UK Ltd in aid of the Ambulance Services Charity, ambulance service employees form across England who have gone above and beyond the call of duty were recognised and commended for their outstanding service. The Outstanding Paramedic Award went to Abigail Evans, a cycle response unit paramedic for London Ambulance Service NHS Trust. The Outstanding Mentor or Tutor Award went to Chris Mathews, a critical care paramedic with South East Coast Ambulance Service NHS Foundation Trust. Outstanding Innovation and Change Awards went to Adam Aston, a paramedic with West Midlands Ambulance Service NHS Trust and Thomas Heywood, a clinical manager for Yorkshire Ambulance Service NHS Trust. The Outstanding Non-Paramedic Clinician Award went to Steve Wainwright, and emergency care assistant for East of England Ambulance Service NHS Trust. The Outstanding Control Services Employee Award went to Craig Foster, a call operator for North East Ambulance Service NHS Foundation Trust. The Outstanding Manager Award went to Karen Gardner, operations manager for North East Ambulance Service NHS Foundation Trust. The Outstanding Support Services Award went to Tez Westwood, Hazardous Area Response Tram support technician for East Midlands Ambulance Service NHS Trust. The Outstanding Senior Management Award went to Tracy Nicholls, head of quality governance for East of England Ambulance Service NHS Trust and the Outstanding Welfare and Wellbeing Award went to Ben Lambert, a team leader for South Central Ambulance Service NHS Foundation Trust.

Workshops allow delegates to discuss emerging themes

The second day, co-hosted by NHS Confederation, featured a morning of facilitated workshops, concluding with a conference summary and forward view. Delegates were given a choice to attend workshops on the themes of ‘our workforce’, ‘technological and digital enablement’, and ‘vanguards and innovation’.

A summary of the main themes discussed in the workforce workshop include the need to engage with staff meaningfully, understanding culture but also taking change, collaboration, and a recognition of whether or not we are doing as much as we can on mental health and race equality.

The technology workshop had a key theme around innovation, and an emphasis that ambulance services are much more than a transportation service. There was a strong feeling that there needs to be better capture and use of data in technological advancements, that procurement needs to be looked at as a whole-systems approach, and that ambulance services should embrace social media.

Within the vanguard workshop there was a clear sense of the great work that is being done across the country. It was recognised that a lot of the components of a really good system are in place, but that we have to learn from each other’s organisations. There was also an emphasis on ensuring that the right culture is in place within services.

With difficulty comes opportunity

The conference came to a close with Anthony Marsh commending the optimism shared by delegates during what is a challenging time for the NHS. He quoted the BBC programme Inside Out, saying there is ‘no need to be miserable, we are winning the war.’ Martin Flaherty, managing director of AACE, then remarked on how sobering it was to hear about the challenging times ahead, particularly around finance. However, he said with difficulty comes opportunity and that as a sector we are always doing our best when in difficulty.

Delegates left with much food for thought and plenty of ideas for implementing change within their own services. Feedback has been positive, with one delegate saying: ‘Excellent conference, completely relevant to our practice in emergency medicine,’ while another remarked: ‘I think the organisation was superb and the quality of speakers and breadth of subject matter was really relevant.’ Congratulations must be extended to AACE for an engaging two days, and delegates can look forward to returning for another year.

Taken from Journal of Paramedic Practice, published 4 March 2016.

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Additional training allows paramedics to treat patients at home

The introduction of specialist paramedic training to the East of England Ambulance Service NHS Trust (EEAST) has allowed for hundreds of patients to be treated at home, avoiding subsequent referral to hospitals and therefore relieving pressure on overburdened A&E departments.

Figures show that in 2013/14, EEAST carried out wound closure treatment in more than 400 patients at their own home.

This comes as welcome news following a report published by NHS Confederation earlier this year, which emphasised the need for more paramedics to be trained to treat at home. The report, entitled Ripping off the sticking plaster: Whole-system solutions for urgent and emergency care, argued for the need of a radical overhaul of emergency care services in order to cope with unsustainable pressures.

Jori Krijgsman, a clinical operation manager for EEAST, said:

‘The treatment ultimately means better care for patients and saves them a journey to hospital. The wound can be treated quickly and effectively through the use of adhesive stitches or dissolvable glue.’

The training has now been introduced to the new student paramedic course, following successful feedback from patients and paramedics. EEAST currently recruits 400 students.

Taken from Journal of Paramedic Practice, published 23 June 2014.

Supporting ambulance service development

Following mounting pressures on England’s emergency care services, the NHS Confederation’s Urgent and Emergency Care Forum has brought together organisations from across the whole health and care system to debate, develop and share ideas for improving urgent and emergency care. The resulting briefing published by the NHS Confederation, which incorporated findings from a survey of 125 senior NHS leaders and an analysis of national data, highlighted a concern that only ‘sticking plaster’ solutions were being offered to overcome pressures placed on A&E departments, rather than solutions which focus on the long-term challenges ahead (NHS Confederation, 2013).

This was followed by a report published on 10 March, which proposed the fundamental changes required to create a sustainable and high-quality urgent and emergency care system that can meet the needs of patients (NHS Confederation, 2014).

One of the key recommendations from the report is the importance of getting the best from the urgent and emergency care system and workforce. Ways in which this could be achieved include improving the education, information, engagement and support available to staff.

In Sir Bruce Keogh’s report on the first stage of his review into urgent and emergency care, he emphasised that fewer patients attended by ambulance crews should be taken to hospital so that pressures on A&E departments are reduced (NHS England, 2013). In order for this to be made possible, the NHS must improve training and investment in its staff. The development of more community-based ambulance services, through enhancing paramedic practitioner roles, is just one of the ways this could be achieved.

This would enable paramedics to take more responsibility for decisions to treat patients on scene and therefore equip them with the necessary skills to establish when it is appropriate to convey patients to emergency departments.

Given that life-threatening emergencies represent approximately 10% of the overall workload for paramedics (Turner et al, 2006), the expectations, behaviours and skills of the workforce need to change. Confidence is dependent on good training and the availability of services to enable efficient referrals where necessary. The development of ambulance services as out-of-hospital providers, in combination with a whole-system approach to urgent and emergency care, will help reduce pressures placed on A&E departments and ensure the needs of patients now and in the future are met.

References:

NHS Confederation (2013) Emergency care: an accident waiting to happen? NHS Confederation, London

NHS Confederation (2014) Ripping off the sticking plaster: Whole-systems solutions for urgent and emergency care. NHS Confederation, London

NHS England (2013) High Quality Care for All, Now and for Future Generations: Transforming Urgent and Emergency Care Services in England—Urgent and Emergency Care Review End of Phase 1 Report. NHS England, London

Turner J, O’Keeffe C, Dixon S, Warren K, Nicholl J (2006) The costs and benefits of changing ambulance service response time performance standards: Final report to the Department of Health. Medical Care Research Unit, University of Sheffield

Taken from Journal of Paramedic Practice, published 4 April 2014.

NHS Confederation calls for a sustainable and high-quality urgent and emergency care system

A response by the NHS Confederation to Sir Bruce Keogh’s review of urgent and emergency care has called for an end to ‘sticking plaster solutions’ and the need for a sustainable and high-quality urgent and emergency care system that can meet the needs of patients.

The report, entitled Ripping off the Sticking Plaster, urges joint work between primary care, acute, ambulance, mental health, social care and community services.

One of the key recommendations from the report calls for getting the best from the urgent and emergency care system and workforce. This would involve improving the education, information, engagement and support available to staff.

Sir Bruce Keogh’s report said fewer patients attended by ambulance crews should be taken to hospital in order that pressures on A&E departments are reduced. The NHS must therefore improve training and investment in its staff, such as the development of more community-based ambulance services, through enhancing paramedic practitioner roles.

This would enable paramedics to take more responsibility for decisions to treat patients on scene and not feel the need to err on the side of caution and transfer patients to hospital.

Chief of the NHS Confederation, Rob Webster, said: ‘We know patients will go “where the lights are on” and instead of blaming patients for going to the wrong place, we need to build a system around patients and to give them the care they need, when they need it.

‘Looking at emergency care in isolation, or just as a hospital problem, without an appreciation or understanding of what is going on across the rest of the NHS and social care will not solve the long-term issues.

‘This will require primary care, acute, ambulance, mental health, social care and community services to work together in networks

‘We need to build on the existing good practice which is out there, but change needs to happen, and fast.’

Taken from Journal of Paramedic Practice, published 26 March 2014.