Health Committee investigation Appendix 1 London Ambulance Service

Introduction The Health Committee is proposing to investigate how to ensure a more modern, efficient and effective emergency ambulance service for London, which is able to meet current and future challenges. This paper sets out the scope of the investigation for approval by the Chair, in consultation with the Deputy Chair.

The proposed terms of reference for this investigation are:

• To examine the key challenges currently affecting the performance of the London Ambulance Service and likely future challenges • To establish how the Mayor and GLA group can better support the London Ambulance Service to provide a more modern, efficient and effective emergency response service for all Londoners • To examine mechanisms for making the Service more transparent and accountable to Londoners

Background The London Ambulance Service (LAS) is the busiest ambulance service in the country. In 2016/17, it handled over 1.8 million emergency calls from across London and attended more than 1.1 million incidents.1 The LAS emergency and urgent care service has the following roles: • Call handling – taking and prioritising 999 calls • 999 emergency and urgent care response • Clinical telephone advice – providing advice to members of the public with less serious illnesses and injuries that don’t need an immediate ambulance response • Dispatching and providing paramedics for London’s Air Ambulance • Planning for, and responding to, large-scale events or major incidents in the capital • The LAS runs the NHS 111 service for south-east London2

The London Ambulance Service is an NHS Trust- the only NHS trust which covers the whole of London. It provides emergency (999) ambulance services and also pre-arranged patient transport. Its 999 services are commissioned by London’s 32 clinical commissioning groups, with Brent CCG acting as lead commissioner. It has over 5,100 staff, based at 70 ambulance stations and support offices across London. The accident and emergency service is split into five operational sectors: north west, north central, north east, south east and south west, aligned with the five STP footprints in London.

The LAS is a critical part of London’s health and emergency response services. For a number of years there have been growing concerns about its performance, which led to the LAS Trust being placed in special measures in 2015 following a CQC review. The LAS faces a number of pressures including increased demand for its services due to changing

1 https://www.londonambulance.nhs.uk/document-search/annual-report-2016-17/ Health Committee investigation London Ambulance Service demographics in London, a difficult financial climate, the potential impact of service reconfigurations across London, and ongoing workforce issues.

The role of the Mayor Unlike the other blue light services, the Mayor and GLA currently have no formal role in holding the Service to account. The Assembly has previously called for this anomaly to be addressed; to make the Service more democratically accountable to Londoners, and to facilitate improved co-working between the LAS, the Met and London Fire Brigade. The Mayor has told Assembly members that he is open to reviewing how the GLA can be more involved in scrutinising the Service: “I believe there is a case for us collectively having a greater role in scrutinising performance and holding the LAS to account because it is clear that it has been underperforming for some time now” (MQT, June 2016)3 The Mayor chairs the London Health Board, which is tasked with strategic oversight of health and care services in the capital following the health and care devolution Memorandum of Understanding between the Mayor and Government. The Board has a number of sub-Boards working on issues with a direct impact on the LAS, including estates, prevention and workforce issues. The Mayor also has a statutory duty to produce a Health Inequalities Strategy which sets out the role of key health partners in London, including NHS trusts. As a pan-London health service, the LAS has a significant role to play in tackling health inequalities. The GLA group itself generates significant demand on the LAS. The number of ambulances called out to police custody suites in London more than doubled, from 2,374 to 5,018, in the past four years.4 Wider issues around access to services, notably mental health services, has contributed to increased demand for ambulance callouts.

Suggested approach The committee is proposing to hold a series of meetings/engagement events to capture:

• The perceptions and views of Londoners on the performance and future trajectory for the LAS • The views of LAS senior management and key strategic partners including the Met, TfL, London Fire Brigade and the NHS. • The views and experience of frontline staff (paramedics and call centre)

The committee may also consider carrying out qualitative and/or quantitative research and site visits to support the investigation.

3 http://questions.london.gov.uk/QuestionSearch/searchclient/questions/question_288130 4 https://www.theguardian.com/uk-news/2017/apr/01/met-police-shortage-nurses-ambulance-call-outs Health Committee investigation London Ambulance Service

Key issues Increased patient demand Over the last five years, demand for ambulances for critically ill or injured patients (category A) has increased at an average year-on-year rate of 6 per cent. This trend is expected to continue and the increased pressure is unlikely to be matched with additional funding. LAS long-term forecasting suggests that if no action is taken to manage demand then the increase for category A incidents will increase to almost 14,000 calls a week, a 30 per cent rise from 2016/17. LAS long-term forecast for rise in category A incidents if no demand management action taken

The reasons for rising patient demand are complex and multifactorial. Contributory factors include: • A growing and aging population, which means more patients and greater complexity, increasing overall demand and lengthening treatment times. Falls account for 11 per cent of all calls to the Service. • Rises in complex physical and mental health conditions that may lead to urgent/emergency responses being required, including high blood pressure and obesity (leading to stroke and cardiac problems), respiratory problems, dementia and mental ill health • Difficulties in accessing primary care and social care, especially out of hours support • Changes to the way patients access and expect to access services • Increased police contact with people with mental health problems, requiring ambulance support • Locally, increased ambulance usage is linked to deprivation. Changes to the socio- economic make-up of areas may therefore increase demand.

Health Committee investigation London Ambulance Service

Performance on response times Response times to category A (life threatening calls) have been subject to considerable local variation across London for some time. For example, in October 2017, against a target of 75 per cent of category calls responded to within 7 minutes:5 The committee may wish to briefly explore the reasons behind these local variations. Possible contributing factors may include: • Demographics of local population • Total number of callouts • Location of ambulance stations within each area • Performance of local A&E departments (handover times) • Staff availability • Other local factors including traffic conditions

The potential impact of service reconfigurations As the only pan-London NHS provider, the LAS is a member of all five London Sustainability and Transformation Partnerships (STPs). However, the Service notes that to date, its ‘participation in strategy and service development has been limited’. This is of concern as it will make it more challenging for the Service to navigate changing complex and variable care pathways across London. More directly, changes to the configuration of London’s A&E departments, for example, will have an effect on how the ambulance service operates, including potentially longer journeys to reach patients and convey them to hospital. Where possible and clinically appropriate, the LAS is looking to shift from a default of conveying patients to hospital, to ‘see and treat’, creating opportunities with other urgent, primary or voluntary services, to provide better care for patients in the community. This will require greater integration and coordination between the ambulance service and the wider health and care sector. The Mayor has committed to providing strategic oversight of the STP process in London, but the analysis commissioned by him to date does not address the ambulance service. The ambulance service of the future The LAS operates out of 70 ambulance stations across London. It is not clear whether these are in the right place to meet existing demand for the services or respond to changing patterns of demand across London. The London Estates Board (a sub-Board of the London health Board) is looking at how to make better use of the NHS Estate in London, potentially freeing up key sites for housing but also potentially allowing for a more intelligent distribution of ambulance sites to improve response times.

5 From November 2017, the way LAS categorises emergency calls changed in line with new standards introduced across the country. Data on how this has affected response times should be available shortly but has not yet been published.

Health Committee investigation London Ambulance Service

Improved access to data – both health data and other sources such as traffic, population movement and environmental information- could enable a more modern and dynamically responsive ambulance service. The Mayor’s Smart Cities programme is currently looking at how to make London a more digitally productive and versatile city. The LAS is also participating in data and tech-based interventions including DASH (looking at how traffic data can support a more responsive service) and GoodSAM (an app which allows trained volunteers to act as emergency responders to local incidents). Workforce Elevated levels of frontline vacancies create operational pressures, increased sickness rates and lower staff morale, resulting in staff retention issues. Call-taking staff, as well as frontline staff, also experience stressful working conditions leading to high turnover and continuing need to train new staff. The LAS has actively recruited for over two years, including from abroad. The current vacancy rate for paramedics stands at around 10 per cent. Higher living costs in London exacerbate retention problems: 30 per cent of London’s paramedics live outside London.6 There is competition for paramedics with other (neighbouring)ambulance trusts and with the widening opportunities for paramedics to work in other care settings including GP surgeries. Vacancy rates for call handling staff are running at around 20 per cent: in a report presented to its board in February 2018 the LAS identified an acute lack of staff at its two main bases as a key risk to its ability to function. Listing the risks faced saying, “The trust may be unable to maintain service levels due to insufficient staff in the emergency operations centre (EOC).”7 The LAS is looking at diversifying the staff who work within the Service to help manage demand. For example, using registered mental health nurses in the call centres to help triage calls to appropriate services. Governance and accountability The LAS is run by a Trust Board made up of 14 members — the Chair, six non-executive directors, two associate non-executive directors and five executive directors (including the chief executive). The chief executive and the other executive directors are appointed through a process of open advertising and formal selection interview. Non-executive directors are appointed by the same method but through NHS Improvement. All executive appointments are permanent. The Assembly has previously called for the Mayor to have some role in appointing Board members to the LAS. With the devolution of health and care powers to London under the MOU with Government and the NHS there may be an opportunity look again at how to make the Service more directly accountable to the communities it serves.

6 https://www.londonchamber.co.uk/LCCI/media/media/Reports%20and%20Surveys/Living-on-the-Edge- Housing-London-s-Blue-Light-Emergency-Services-Report.pdf?ext=.pdf 7 https://www.londonambulance.nhs.uk/wp-content/uploads/2018/02/Trust-Board-Agenda-and-Papers-27- February-2018-1.pdf Health Committee investigation London Ambulance Service

Key questions What are the key challenges currently facing the LAS? What factors are contributing to falling performance against response time targets across London? Are different solutions needed in different sub-regions of London? How will potential service reconfigurations affect LAS performance? How involved has LAS been in planning for these changes? What do people want and expect from a modern LAS? What, if anything, can be done to reduce demand for ambulance services? How can the Mayor contribute? What key groups/issues need to be engaged/addressed? What impact have changes to mental health and social care provision had on demand for ambulance services? What can be done to improve recruitment and retention of LAS staff? How can the Mayor and the wider GLA group support the LAS to achieve better health for Londoners? Does the LAS have the data and technology it needs to meet future challenges?

Possible guests

Patients Forum, London Ambulance Service (and service users) Royal College of Emergency Medicine/College of Paramedics Local directors of public health/social care NHS England (London) The London Ambulance Service Chair/Chief Executive Metropolitan Police London Fire Brigade Transport for London Community and voluntary groups

Output The committee will produce a range of outputs to highlight the key findings of the investigation, and make recommendations to the Mayor on areas for action.