Quality Account 2020/21

1 Contents Introduction 3 Declaration of accuracy 5 Part One: About us 6 Our values 6 Our vision 6 Area we cover 8 Our service 8 Part Two: Looking back - review of quality improvements in 2020/21 12 Our 2020/21 priorities and progress made 12 Commissioning for Quality and Innovation (CQUIN) 15 Care Quality Commission 23 New services and innovation 24 What we have done to improve patient safety 25 Learning from incidents, experiences and feedback 25 Duty of Candour 25 Serious Incidents (SI) 26 Learning from deaths 27 Prevention of future deaths 29 Harm reviews 29 Freedom to Speak Up 30 What we have done to improve patient experience and engagement 31 EMAS Patient Voice Forum 30 Compliments 32 Formal Complaints (FC) 32 Ombudsman requests 34 Patient stories 35 Extracts from messages of thanks during 2020/21 34 Corporate communications and engagement 39 Staff communications and engagement 40 Social media and media engagement 41 Equality, diversity and inclusion 42 Part Three: Looking forward - what we want to do better in 2021/22 44 Our quality improvement strategy 44 Quality priorities for 2021/22 45 Appendix 1: Quality Improvement Strategy Year 1 progress; Year 2 priorities 48 Appendix 2: Workforce 63 Appendix 3: Data Security and Protection Toolkit (formerly IG Toolkit) 84 Appendix 4: What we have done to improve clinical effectiveness – R&D 85 Appendix 5: CQC registration 111 Appendix 6: Third Party Statements 112 Appendix 7: EMAS Trust Board 124 Director’s responsibilities in respect of the Quality Account 125 Glossary 126 Contact details 129

2 Introduction

This year really has been one unlike any other, with the COVID-19 pandemic dominating all of our lives and every facet of EMAS’ work. I cannot begin this report without expressing my huge gratitude to each and every one of our staff members for their hard work throughout this most difficult of years.

While this year has been incredibly tough, I have seen the determination, dedication and sacrifices people have made day in day out. But in many ways I have seen the staff of the East Midlands Ambulance Service rise to the challenge and shine.

From the frontline staff who have come into work every day, despite fearing for their own safety and that of their families, to the Fleet team who’ve gone above and beyond to keep our vehicles on the road and the Logistics team who have kept them supplied with personal protective equipment (PPE), and to all the staff that have had to adapt to working from home and all the challenges that brings with it. I am so proud of the collective efforts that have been made and the level of care we have continued to provide for our patients throughout.

Wherever our staff work, whether it is patient facing, in the control room or in supporting roles, they have often stepped into territory and new job roles almost overnight and it really has been a true team effort.

Many of our staff have been personally affected by COVID-19; whether they’ve contracted the illness themselves, looked after or even lost family members. Our thoughts remain with the family and friends of our colleague and volunteer teams who lost their life to the disease. Their tragic loss has impacted everyone at EMAS and brought home the very real impacts of the disease.

What the pandemic has done is it has allowed EMAS to do what it is best at – responding to patients. From the outset we have been able to get to patients faster than we have ever been able to get to them before but patterns have changed with staff finding themselves spending more time with patients or more time handing them over to the care of hospital colleagues. And all of this whilst having to wear additional layers of PPE for lengthy periods.

Despite what has happened, we have improved. Across all of our divisions, we have worked collaboratively with Acute Trusts to facilitate temporary and permanent pathway redesign to support the response to COVID-19. At all points, EMAS has supported these changes in a way that ensured we maintained our service level to our patients, both in terms of response and quality of service given. From a service user perspective they will have seen us speed up our response times and improve our care.

We have taken a leading role in national resilience, which has been recognised by other ambulance services, as well being mentioned in the House of Commons by the Health Secretary. Where other areas have declared emergencies, colleagues from the East Midlands have stepped up. For example the roll out of the digital gateway has meant that 3 some patients were calling from London, it was picked up by our control centre staff here and relayed back to the patients locality: the individuals would not even know that has happened, with no loss of care.

Aside from our operational duties, we became classed as a ‘hospital hub’ and vaccinated our own staff across a wide geographical region.

This followed on from us being the top performing ambulance service in the country for flu vaccinations and one of the best in the region if you take into account the huge spread and number of our people across our service.

We’ve also seen an excellent take-up of the COVID-19 vaccine among our staff, exceeding NHS targets, something that should help to stand us in good stead for the coming year.

Communication and engagement has also improved, as we have had to adapt quickly, we have used new platforms and live sessions where we can interact with staff. Our Staff Survey results have also improved. We have seen significant improvements in the survey questions that are used to calculate the Freedom to Speak Up Index, a measure of the Trust’s open, learning and improving culture. We have also introduced new initiatives to share learning from when things go well, not just when they go wrong, with fortnightly Learning from Events sessions hosted by our Quality and Clincial directorate teams. The initiative has been introduced as part of our new Quality Improvement Strategy 2020-2025 priority objectives.

And despite the pandemic we also rolled out the new specialist practitioner role, introduced to provide more advanced clinical care to patients that would have traditionally needed conveyance to hospital for certain procedures. The role has been introduced as part of our Big 3 vision and strategic objectives.

We also moved to having a GP or senior medic on site in our control room seven days a week which has been very effective.

Despite the many difficulties the pandemic has brought with it, there have also been many positives during the year and lots of reasons to be hopeful for the future.

We’ve been part of some wonderful partnership working with blue-light colleagues across the region and, indeed, the country. Our participation in the emergency services mutual aid scheme saw our call-takers help out ambulance services from across the UK during the busy winter period. While closer to home we worked with the fire service to train firefighters to work alongside our Urgent Care colleagues.

This spirit of collaboration is also part of our plan to co-locate with blue light services in many of our divisions such as the new blue-light tri-hub at Hucknall, Nottinghamshire, where we are based alongside police and fire service colleagues.

4 I’d like to take this opportunity to thank all of our partners across the health service and blue-light services for all that they have done to support and work with us during this difficult year.

Looking to the future, we’ve made fantastic progress this year with reducing the number of patients that are taken to hospital when they could be looked after safely at home, something that I hope continues to be part of our ‘business as usual’ once the pandemic has receded.

In the coming year, the recovery and restoration phase will be really important to us – many many, people have gone above and beyond. We need to have a period of consolidation, we need to recognise and value each other, learning from what has happened. We need to embed those positive changes while reflecting on areas of challenge.

Afad

Richard Henderson Chief Executive

Declaration of accuracy

I confirm that to the best of my knowledge the information presented in our Quality Account is accurate.

Richard Henderson Chief Executive Richard Henderson Richard Henderson Chief Executive

5 Part One: About us

East Midlands Ambulance Service (EMAS) provides emergency and urgent healthcare and patient transport services.

Our values

EMAS has five values, designed by staff and stakeholders, which underpin everything we do, including the way we deliver our services and how we work with others. By living these values and supporting others to do the same, we will help to make sure that EMAS is an organisation we can all be proud of.

• Respect: Respect for our patients and each other. • Integrity: Acting with integrity by doing the right thing for the right reasons. • Contribution: Respecting and valuing everyone's contribution and encouraging innovation. • Teamwork: Working together, supporting each other, and collaborating with other organisations. • Competence: Continually developing and improving our competence.

Our vision We engaged with colleagues and stakeholders to seek their views on our vision and strategic priorities. The final versions were originally approved by our Trust Board in October 2018, these were refreshed during 2019 and again in 2020 as shown below.

Our vision is to be ‘Responding to patient needs in the right way, developing our organisation to become outstanding for patients and staff, and collaborating to improve wider healthcare.’

1) Respond - we will respond to patient needs in the right way

• We will safely treat patients at home where possible, while helping to improve our patient pathways options with feedback from our clinicians. • We will strive to have an inclusive workforce, representative of the public we serve, with a skill-mix to deliver high quality care to patients, in line with our clinical operating model. • We will focus on ensuring we get the right response from the outset for the patient, using the combination of clinical oversight and technology. • We will continually improve our control room functions, including our approach to critical care. • We will strive to consistently deliver the Ambulance System Indicators and Ambulance Care Quality Indicators.

6 2) Develop – we will develop our organisation to become outstanding for patients and staff

• We will use patient, staff and wider stakeholder feedback to develop our services. • We will continue to develop an organisation that staff and volunteers are proud to work for. • We will seek to develop a culture where staff wellbeing is integrated into day-to- day practice; creating a sense of belonging and support. • We will develop our career opportunities for both clinical and non-clinical staff across the organisation. • We will continue to develop and improve our estate. • We will strive to achieve a Care Quality Commission rating of ‘outstanding’ and will consistently meet our financial targets. • We will develop our capacity and capability to improve quality within the organisation and will embed quality improvement in our day-to-day practice.

3) Collaborate – we will collaborate with partners and other organisations to reduce healthcare demand and improve wider healthcare

• We will develop our approach to working with partners in the health and social care system, specifically forging new partnership structures and becoming an active partner and strategic influencer in their developments. • We will work with partner organisations to develop our approach to supporting mental health. • We will develop a closer working relationship with our partners in 111 to deliver the most appropriate healthcare to patients. • We will continue to help reduce demand on services by focusing on public education on urgent and emergency care, including non-emergency patient transport services (NEPTS). • We will explore and exploit opportunities within the Northern Ambulance Alliance, where collaboration will enhance patient care and efficiency. • We will work in collaboration with others to reduce our carbon footprint and become more sustainable in the running of our organisation.

7 The area we cover There are large differences in population density across the East Midlands – from the highly concentrated urban areas and more dense population corridor along the M1, to the low-density rural areas in the east.

Two of the UK’s mainline railways serve the region, providing regular high-speed services.

There are several airports within our region, with the largest being East Midlands Airport serving over four million passengers a year.

The East Midlands is home to numerous entertainment venues including major sporting venues, national parks and forests, the East Coast, music festivals, the National

Space Centre, holiday and caravan parks.

Our service

Our annual turnover was £255 million in 2020/21, which included additional COVID-19 funding. We are paid to provide services by 10 clinical commissioning groups (CCGs) based across the East Midlands. We deal directly with the A&E contract lead in NHS Derby and Derbyshire CCG, which represents the other CCGs in the region.

We provide emergency and urgent services for 4.8 million people, covering approximately 6,452 square miles across six counties of Derbyshire, Leicestershire, Lincolnshire, Northamptonshire, Nottinghamshire and Rutland.

A total of 3,983 people are employed at 70 facilities, including ambulance stations, community ambulance stations (smaller facilities, often shared buildings with other organisations allowing our crews to ‘stand-by’ in strategic locations in-between responses to 999 calls), two Emergency Operations Centres, training and support team offices and fleet workshops.

Our Emergency Operations Centres (EOC) based in Nottingham and Lincolnshire received 2,526 calls on average each day (one every 34 seconds), receiving 3,477 on our busiest day during 2020/21. As of March 2021, we have around 180 emergency medical dispatchers answering 999 calls from the public and 110 dispatch officers ensuring the most appropriate resources are sent to help patients.

We also have a Clinical Assessment Team (CAT), which consists of paramedics, nurses, midwives, and mental health practitioners. They undertook circa 70,000 ‘Hear and Treat’ events during the year. Team members provide clinical advice to patients and operational staff signposting them to services and places where alternative, more appropriate care can 8 be provided. This allows our ambulance crews and hospital colleagues to provide face-to- face care and treatment to those who are in most need.

Our frontline accident and emergency ambulance crews represent the largest staff group at EMAS, and we operate a fleet of 733 operational vehicles, including emergency ambulances, fast response cars, specialised and driver training vehicles, and urgent care and patient transport vehicles.

We receive valuable assistance from many Community First Responder (CFR) schemes providing emergency cover mainly in all the areas we serve, with 1,650 individual CFRs in patient facing roles.

Over 50 EMAS colleagues operate as medical first responders providing support when they can attend emergency incidents in their local area and in their own time.

Most recently the CFR team has worked tirelessly to support the regional and local (EMAS) COVID-19 mass vaccination rollout programme in administrative, marshalling, first aid and vaccinator roles.

We also benefit from the invaluable presence of three separate air ambulance services which respond across the region and are operated by registered charities (The Air Ambulance Service, Lincs and Notts Air Ambulance and Magpas Air Ambulance).

In addition, we have a team of 24 doctors – the East Midlands Immediate Care Scheme (EMICS) - who volunteer their time, working over and above their normal general practice or hospital work, to provide both a primary response role to life-threatening calls and clinical support for crews at serious clinical incidents such as road traffic collisions.

We continually strive to further improve patient care by ensuring that patients consistently receive the right response first time. Our approach also means that more patients will be treated in the community, and fewer people will go to a busy hospital emergency department (ED) unnecessarily.

EMAS provides a Non-emergency Patient Transport Service (NEPTS) in Derbyshire and Northamptonshire for eligible NHS patients who need medical or clinical support to get to and from their healthcare appointment.

During 2020/21 we undertook 17,500 journeys across the two counties, 2,500 less than last year due to fewer outpatient clinics and appointments as a result of the COVID-19 pandemic.

The service took 11,800 phone calls from NHS colleagues and patients to make or amend a journey booking.

In December 2020 we were really proud when our NEPTS volunteer car service team, who spare their time to consistently deliver a fantastic service under all circumstances, won

9 Volunteer Team of the Year at the East Midlands Charity Awards. A true accolade for a very deserving team.

We also employ staff in a wide range of support roles including human resources, organisational development, information technology, patient experience, patient safety, infection prevention and control, safeguarding, clinical audit and research, communications, transformation, logistics, procurement, governance and medicines management to name just a few; without whom we would not be able to provide an effective service.

During 2020/21 the health and social care system continued to face huge pressure and significant challenges which impacted on our ability to respond to emergency calls and meet the government standards. Throughout 2020/21 we continued to support the regional system response to the COVID-19 pandemic. We put into practice our Emergency Planning, Resilience and Response plans and processes to support both our response to the pandemic and to maintain frontline services for all patients in need.

Nationally, emergency department colleagues are required to accept a clinical handover from our ambulance crews when they arrive at hospital with a patient within 15 minutes. At times, handover delays continued to place EMAS under extreme pressure and remained the focus of much attention. During 2020/21, EMAS lost 59,759 hours to pre-hospital handover delays (32,329 fewer than compared to 92,088 hours lost during 2019/20). However, this is in the context of 54,000 fewer attendances to emergency departments.

Fundamentally, the risk associated with handover delays is to patients waiting in the community, often without a medical professional present, for a 999 ambulance response. The situation also has an impact on staff wellbeing, morale and sickness levels.

Our Executive Team and local senior management teams continue to act to manage and mitigate the risk that the hospital handover delays create. Reports providing updates and detailing actions taken have been submitted during the year to the Trust Board meetings held in public, and concerns, particularly relating to issues out of our direct control or influence, continue to be escalated to organisations that regulate, commission and monitor EMAS services.

During 2020/21 we worked with our Acute Trust colleagues and NHS England and NHS Improvement as part of an improvement collaborative and implemented a Regional Conveyance Policy outlining actions to escalate and address handover delays and mitigate the risk of harm. We participated in NHS England and NHS Improvement ‘Missed Opportunity’ audits to assess the appropriateness of hospital conveyances and identify what pathways would need to be in place to safely reduce attendances to ED. We continue to work with system partners to identify and implement these pathways including Same Day Emergency Care pathways and direct access to specialties such as surgery, gynecology and urology.

We have also contributed to national work, via the National Ambulance Service Quality, Governance and Risk Directors Group, in developing a standardised approach to assessing 10 the potential for harm associated with handover delays and resulting prolonged waits for a response in the community and to the development of national guidance, produced by the National Ambulance Service Medical Directors Group, aimed at promoting safety and preventing harm during prolonged hospital handover delays

In addition to our core services, we provide a range of other key services including:

• Specialist transfers: inter-hospital transfers that include adult critical care or for specialised surgery, paediatric and neo-natal care.

• Hazardous Area Response Team (HART): a dedicated team providing specialised cover for civil contingencies, major incidents and chemical, biological, radiological and nuclear (CBRN) incidents.

• Emergency Preparedness and Business Continuity (regional resilience): a service that ensures we are prepared to deal with a range of civil contingencies and major incidents. It works closely with the six local resilience forums across the region, each of which includes local authorities, police and fire services. This also ensures business continuity in the event of a civil contingency or other adverse event that affects normal operations.

• Bariatric transfers: specialist services and equipment to transport bariatric patients (our bariatric ambulances can transport patients with a weight of up to 50 stone).

• Community Public Access Defibrillators (CPAD): we have placed life-saving equipment in local communities across the East Midlands. Defibrillators are used when someone has gone into cardiac arrest (ie when the heart stops pumping blood around the body), to give the heart an electric shock to allow effective cardiac rhythm to be re-established.

• Events support: a commercially available team that provides professional emergency medical support to special events such as sporting, musical and athletic showcases across the region.

• Admission avoidance schemes: provided through a number of schemes across the East Midlands including Falls Partnership Services and mental health nurse with an EMAS paramedic responding to related calls in a fast response car.

11 Part Two: Looking back - review of quality improvements in 2020/21

This part of the Quality Account demonstrates our achievements during the year 2020/21. Part Three identifies the improvements we plan to achieve in the coming year.

We are required to achieve a range of performance outcomes specific to the nature of the services we provide to the public. In addition, we are required to achieve many other organisational responsibilities, as laid down by the Department of Health.

Our 2020/21 quality account priorities and progress made

We identified improvement priorities against the three domains of quality:

• clinical effectiveness • patient safety • patient experience

Progress: As a result of the COVID-19 pandemic response we have been unable to make as much progress as we would have liked in this area. We have Priority 1: To improve the way in however increased the membership of which we listen to and use our Nottinghamshire and Derbyshire feedback from our patients, carers Patient Voice Groups and initiated a and families to continually new group in Lincolnshire. Groups have continued to meet virtually throughout improve our services. We will do the pandemic and have continued to this by expanding our patient support the Trust in ensuring the patient voice groups and ambassador voice in considered in service roles in terms of both numbers development. During 2020/21 the Caring and diversity, implementing groups supported the development of revised patient feedback for the Trust’s Quality Improvement Strategy and supported the ambulance services and implementation of a bereavement developing a metric to capture booklet. They have also supported a compassion, kindness, dignity and complaints and media release review respect in action. and supported improvements to a patient advice leaflet for safe discharge Lead: Director of Quality on scene. Improvement and Patient Safety It is recommended that this priority is carried through to 2021/22 so that further work can continue.

12 Progress: Significant progress has been made in this area during the year. Alternative pathways have been Priority 2: To work in developed in collaboration with system collaboration with our system partners and with the support of partners to identify and utilise dedicated pathway leads in division. appropriate pathways to meet the Senior clinical support has been individual needs of our patients. available via the CAT and a newly We will do this by identifying gaps introduced Clinical Coordination and in provision, promoting the use of Support Desk providing clinical advice Responsive appropriate alternative pathways and supporting crews to identify to ED, expanding the use of appropriate alternatives plus telemedicine and providing senior implementation of Specialist clinical advice and leadership Practitioners. This has all been supported along with access to shared by increased access for crews to patient patient information to support records and use of videoconferencing. crews in their decision making. We have seen almost a 10% reduction in ED conveyance during 2020/21 (2019/20 Lead: Medical Director outturn non-conveyance to ED was 33.49% compared to 42.83% in February 2021). Progress: During 2020/21 we ran a successful pilot of Cardiac Arrest Leaders (CAL) in the Lincolnshire Division. This Priority 3: To improve our involved a senior clinician with performance against the enhanced training being dispatched to nationally reported Ambulance cardiac arrest calls to provide senior Clinical Quality Indicators, with a oversight of the arrest management and particular focus on cardiac arrest. immediate debrief and learning. This We will do this through a robust demonstrated significant improvements audit programme, effective in Return of Spontaneous Circulation clinical leadership, sharing (ROSC) and is now in the process of learning and implementing being rolled out Trust wide. The Trust Effective improvement strategies. undertook focused work on the impact of the pandemic (due to the Lead: Medical Director requirement for staff to don Level 2

personal protective equipment) on ROSC * Utstein Group - patients who had resuscitation commenced/continued by rates for arrests with a shockable rhythm the ambulance service following an out which provided reassurance that there of hospital cardiac arrest of presumed was no adverse impact. As at Feb 2021 cardiac origin, where the arrest was ROSC in the Utstein Group* had bystander witnessed and the initial deteriorated by 4.48%, Survival to rhythm was VF/VT (shockable) Discharge had improved by 0.3% and compliance with care bundle improved by 54.1% compared to Mar 2020.

13 Progress: During 2020/21 we have introduced fortnightly Learning from Priority 4: To foster a just safety Events sessions open to all staff and culture which supports continuous volunteers. These have focussed on learning and improvement and learning gleaned from various sources supports our staff to be the best including complaints, compliments, they can be. We will do this by incidents, audits and inquests. The working in collaboration with sessions are coordinated by the clinical system partners to learn from and quality directorates and involve when things go well not just when subject matter experts (including things go wrong. We will external speakers where relevant), staff implement innovative approaches and/or patients involved. The sessions to ensure that lessons learned are Well Led are designed to ensure maximum shared and embedded widely sharing of learning. We also now including using appropriate social routinely complete Excellence Reports media and technology. We will where audits or reviews identify develop a network of quality excellence in practice so that staff improvement champions and receive appropriate recognition and support them in identifying, acknowledgement. The results from the implementing and evaluating 2020 NHS Staff Survey indicate an innovations in practice. improving culture, with a 10% increase

in staff reporting that they believe that Lead: Director of Quality staff involved in incidents are treated Improvement and Patient Safety fairly.

Progress: A revised Serious Incident procedure was implemented in 2020/21. Priority 5: To improve the quality Twice weekly multi-professional Incident of our serious incident Review Group meetings were introduced investigations to maximise to review cases and ensure appropriate learning and reduce the risk of escalation. A confidential session was harm in our services. We will do introduced including HR colleagues to this by training our staff to consider staff allegations. Just Culture is undertake robust root cause applied to all parts of the process. We analysis investigations to better have also introduced multi-professional identify causes and contributory Safe Root Cause Analysis panels to factors and by working with investigate serious incidents and ensure representatives from clinical, that robust actions are implemented to quality, operational, HR teams prevent recurrence. New style 72-hour and system partners to identify initial reports and final reports have and implement recommendations been developed and these have received to address these. positive feedback from commissioners

and regulators. We have seen a Lead: Director of Quality significant improvement in closure of Improvement and Patient Safety serious incident (SI) reports at first submission.

14 Commissioning for Quality and Innovation (CQUIN)

As part of the NHS Standard Contract, 1.25% of EMAS’ income is usually dependent upon the organisation achieving quality improvement goals through innovation.

CQUIN schemes are an opportunity for providers to ensure a key focus on quality improvement. The outcomes from these schemes can be significant and impact directly on patient care. During 2020/21 the CQUIN scheme was suspended as a result of changes to the contractual process due to the COVID-19 pandemic.

However, EMAS was keen to continue to focus on delivering schemes that make significant changes to the lives of our patients and their outcomes.

National CQUINs

For the 2020/21 contract no national CQUIN schemes were mandated for ambulance services, but EMAS continued to monitor delivery against the previous year’s CQUIN schemes:

Flu vaccination CQUIN Frontline healthcare workers are more likely to be exposed to the influenza virus, particularly during winter months when some of their patients will be infected. It has been estimated that up to one in four healthcare workers may become infected with influenza during a mild influenza season - a much higher incidence than expected in the general population.

The 2019/20 national flu vaccination CQUIN was a continuation of the previous year’s Health and Wellbeing CQUIN, this was nationally mandated by NHS England and applied to all NHS contracts (where appropriate).

For 2019/20 the expectation was that all NHS trusts would achieve an uptake of the flu vaccination by 80% of all frontline staff (those working directly with patients or in frontline support roles such as those working in the EOC) to reduce the risk of both staff and patients getting infected with influenza. Whilst there was no CQUIN payment associated with the flu campaign in 2020/21 it was widely expected that Trust’s would improve on the previous year’s target and achieve 90% vaccination of all frontline staff. We therefore undertook to offer the flu vaccination to 100% of staff and to vaccinate as close to 90% as possible.

As we were aware that during the 2020/21 winter season we would have the added expectation of delivering the COVID-19 vaccination to our staff we opted to accelerate our winter flu vaccination campaign delivery by compressing what is usually a five month programme into just over two months. We offered the free flu jab to all our staff between October 2020 and December 2020 as part of our health and wellbeing campaign and 88% of colleagues had the vacination. Athough we did not achieve the 90% target this was a significant improvement on the previous year when 80.1% were vaccinated. This resulted in us being the ambulance service with the highest rate of flu vaccination 15 and the third highest provider in the region. Our flu vaccination team approached 100% of colleagues to offer them the jab. Their hard work has helped us to carry out our campaign to protect as many of our workforce and patients from the flu as possible.

In December 2020 our application to become a COVID-19 vaccination hub was approved and we embarked on our campaign to offer the COVID-19 vaccination to all of our frontline staff and support staff in the Joint Committee on Vaccinations and Immunisations (JCVI) priority groups 1-9. We’ve also seen an excellent take-up of the COVID-19 vaccine among our staff, exceeding NHS targets, something that should help to stand us in good stead for the coming year.

National access to patient information at scene CQUIN This national ambulance CQUIN incentivised ambulance trusts to ensure their systems allow their clinical staff at scene to have immediate access to patient information. The aim of the CQUIN was to provide frontline staff with more detailed and accurate data about the patient, such as medical history, medicines and allergies, and any care plans that are available to them. This will, in turn, support decision-making, referral into appropriate pathways of care and safely reducing avoidable conveyance to hospital.

The CQUIN was made up of two parts; the first element was to ensure EMAS has the functionality to access patient information at scene, this was to be achieved by the 1 October 2019; the second element following on from successful implementation (from 1 October onwards) was to achieve a minimum of 5% of all on scene responses having patient information accessed by EMAS clinicians at scene. We fully achieved both elements of this CQUIN.

Again, whilst this CQUIN was not formalised in the 2020/21 contract the Trust continued to monitor against the target of 5% per quarter required to achieve compliance. We continue to significantly overachieve this and are committed to increasing the use of technology to access shared information to inform effective clinical decision making. The occasions on which staff attempt to access GP information and the times that this is successful has continued to increase month on month throughout 2020/21 with results for March 2021 (as at 25 March 2021) as shown in the table below.

% % Month Activity Attempts Success Attempts Success Mar-21 49948 29196 27413 58.5% 54.9%

Locally agreed CQUINs

There were no locally agreed CQUINs during 2020/21 due to suspension of the normal contractual processes as a result of the COVID-19 pandemic. However local service improvement initiatives have continued in each area despite the challenges of the pandemic response.

16 Derbyshire A&E

During 2020/21 in the Derbyshire Division we:

• Worked closely with acute hospitals to develop COVID-19 pathways for both ED and other areas/specialties • Introduced the Clinical Development vehicles to provide support to staff when required • Achieved over 90% flu vaccination target • Introduced a dedicated Reducing Conveyance Lead • Worked with acute hospitals and other partners to develop/expand alternative care pathways including o Urology pathway o Access to Same Day Emergency Care units o Respiratory pathway o Relaunch of Urgent Care Centre Pathway with consistency across all sites • Worked collaboratively with care homes to improve working practice o Continued roll-out of CHAMPs (Care Home Ambulance Promise) – a joint initiative with care homes aimed at making explicit the expectations of both ambulance and care home staff to ensure seamless transition of care o Enhanced Care in Care Homes – worked with five care homes to reduce 999 incidents related to falls by introducing the ISTUMBLE App and securing five Mangar Elks for trial within these homes • Worked with partner agencies to continue to support the homeless community in Derby including a dedicated paramedic working in the community to tackle the health inequalities in the entrenched homeless community • Rolled-out Alternative Pathways Ambassador initiative across the division to increase confidence and promote appropriate non-conveyance amongst all staff groups • Introduced inappropriate conveyance audits and liaised directly with system partners to improve availability of and access to pathways • Mental Health Triage Hub- secured access 24 hours a day, seven days a week increasing referrals threefold • Introduced an End of Life Care Cell with system partners throughout the pandemic • Introduction of the Additional Capacity Clinical Operations Manager role to support staff and provide additional support and guidance around the role they play in supporting the wider health economy

17 Emergency Operations Centre

Within EOC we have throughout the pandemic response made rapid changes to improve patient and staff safety, learning and adapting daily as we set out on this journey. In addition to the achievements set out below there are also a number of further improvements that are outlined in the new services and innovation section later in this quality account.

EOC form a robust membership to the Trusts Incident Review Group (IRG), ensuring there are subject matter experts on hand to review every step on the patient journey; from first 999 contact to the dispatch and EOC clinical elements, to giving clear concise feedback, and taking away any learning and discussing at the EOC Learning Review Group. This also forms the basis for the Trust’s re-accreditation to the International Academy of Emergency Dispatch maintaining this for over 12 years and still being the world’s first multi-site ACE Accredited EOC.

Within our EOC we have regional operations managers (ROM) who support hospital turn arounds, and ensure smooth running of the service; challenging where there are pressures, feeding back directly to NHS England and the National Ambulance Coordination Centre (NACC) to develop strategies to support and assisting in the efficient and safe running of the service. Our ROMs are on duty 24/7 to assist and support in a central role with our partners at National Ambulance Resilience Forum (NARU) in dealing with any high acuity incidents the Trust respond to.

EOC have developed best practice templates for both the Quality Impact Assessment (QIA) and Equality Impact Assessment (EIA) to ensure comprehensive risks and learning can be captured, to offer a full appraisal to our peers of any change to process or policy to capture in our key lines of enquiry through the Care Quality Commission (CQC) and also linking directly back to the Trust’s Quality Agenda.

EOC also piloted and supported the development of a Rapid Improvement Tool to monitor and improve compliance with infection prevention and control prior to this being rolled out Trust wide. This is now used routinely across the organisation to provide assurance of robust IPC practices to the Trust Board, regulators and commissioners and has been able to evidence significant improvements in levels of compliance since its introduction.

The challenges throughout 2020/21 have been incredibly testing both physically and mentally for our colleagues in the EOCs. We continue to respond to prevailing change, delivering a high-quality service to our patients and collaborating with internal and external stakeholders to deliver priorities across the Trust. Despite the challenges and competing pressures of the past year the quality and innovation agendas have taken a huge step forward.

18 Lincolnshire

In Lincolnshire we have introduced Cardiac Arrest Leaders (CAL) across the division, 84% of the time a CAL is on scene within 15-20 minutes. 71% of calls that are transported have a paramedic on board. 29% have a ROSC at hospital which is higher than cases where a CAL is not present. We continue to train our Fast Response Vehicle (FRV) paramedics, clinical operations managers (COM) and clinical support managers (CSM) on this.

We have also introduced the role of Pathways Coordinator to work collaboratively with system partners to ensure that there are appropriate alternative pathways in place and that staff feel confident to use them. This has had a significant impact on non-conveyance levels with rates of non-conveyance increasing by over 12% over the past year (2019/20 outturn non-conveyance to ED 28.76%; February 2021 41.15%). A patient case study was recently presented to the Lincolnshire Urgent and Emergency Care Delivery Board featuring the joint management of a 101-year-old patient by EMAS and the Community Emergency Medicine Service (CEMS) which enabled the patient to stay safely in her own home with community support, in line with her wishes.

We have introduced senior manager audits of all stations to supplement the IPC/COVID safe audits. Once per quarter an ambulance operations manager visits the stations in their area, we then rotate so we don’t always audit our own stations.

As a result of feedback from road staff we have developed a better system for support for staff going through SI/investigation process. We have had some really good feedback around this and have spoken on Learning from Events sessions to that effect.

We have continued to complete harm reviews into both hospital handover delays and prolonged waits for a response in the community and have begun to look for patterns, eg time of day, category of call, current Capacity Management Plan level, age of patient, etc. We have worked in collaboration with the teams at United Lincolnshire Hospital Trusts to undertake the handover delay harm review work jointly.

Despite the pandemic our CSMs have continued to deliver Continuing Professional Development via Microsoft Teams. These have been developed from SI outcomes and common themes from incidents.

We engage with our private providers to ensure they deliver the same quality metrics as we aim for.

We have improved our system for supporting the central Coroners team and we have had feedback from the Coroners team in relation to this. We ensure a manager is with the member of staff and is supported whilst writing statements and throughout the inquest process.

19 Leicester, Leicestershire and Rutland (LLR) and Northamptonshire A&E

During 2020/21 in both the LLR and Northamptonshire Divisions we:

• collaborated with the Acute Trusts regarding pathway changes and process changes in response to the COVID-19 pandemic • successfully delivered the initial phase of the COVID-19 vaccination programme • successfully delivered the flu vaccination campaign • implemented Resuscitation in PPE training sessions at the start of the pandemic – to improve staff and patient safety • delivered face to face validation for resuscitation metrics in line with the Trust 95% standard • implemented Mental Health Hubs across LLR and Northamptonshire • supported Learning from Events sessions with cases specific to division to improve quality and safety of care.

In LLR specifically we:

• achieved 43.11% conveyance to ED (against response) – best performance throughout divisions (over 8% lower conveyance than the next best performing division) • introduced Pre-transfer Clinical Discussion and Assessment (PTCDA) to facilitate senior geriatrician advice in the community to reduce conveyance, or direct access to a ward to ensure non-ED conveyance • Introduction of Physician Response Unit (PRU) to support improved patient care/senior advice at point of assessment • Implementation of Hospital Handover Harm Prevention pilot to improve patient safety during prolonged waits on the back of an ambulance.

In Northamptonshire specifically we:

• reduced conveyance to ED (against response) to 55.79% • supported the frailty improvement collaborative across Northamptonshire to support the systems five-year plan for reducing conveyance/admissions for frail patients and support increased care in the community • implemented medical Same Day Emergency Care (SDEC) pathways at both acute sites (NGH/KGH) • completed joint Continuing Professional Development sessions virtually with community services to promote alternative care pathways.

20 Non-emergency Patient Transport Services (NEPTS) - Derbyshire and Northamptonshire

During 2020/21 in NEPTS we:

• have worked closely with system partners by being part of integrated teams, particularly those set up to manage the early stages of the pandemic, that have grown into well-established successful forums that have effected change. For example, the Strategic Discharge Group and Care Pathways groups within Derbyshire. Northamptonshire has seen the inclusion of NEPTS at its systemwide discussions and has seen the relationship positively develop into further established groups • introduced a clinical lead to support continued education, development and an integrated approach with A&E divisions and healthcare services • Became the COVID-19 discharge coordination lead for the region; ➢ Set up a single point of contact ➢ Established a collaborative approach with non-NHS NEPTS providers within the region ➢ Daily discussions, NHS England and NHS Improvement reporting and escalation process • introduced home working for the call taking function. New technology enabled this to be undertaken quickly to support the COVID-19 national guidance and has enabled NEPTS to evolve the call taking model for the future • developed Service Delivery Principles with commissioners to support the delivery of continued high-quality patient care and experience during the pandemic • established a wellbeing operations manager role following feedback from staff and learning from actions undertaken and review of NEPTS initial response to COVID-19 • the NEPTS volunteer lead developed and managed non-driving volunteer roles to support the Trust, in particular the fleet team in the distribution of PPE • integrated managers within acute sites and renal departments in Northamptonshire • worked collaboratively with local authority and community services above contractual requirements to provide support in exceptional circumstance • staff have continued to comply with mandatory education requirements despite numerous challenges • developed a standard operating procedure to support frontline and control centre staff with all elements of IPC, PPE and patient transfers in line with national guidance • developed a patient call ahead system to safely triage patients ahead of each journey • set up a vehicle design team to work with Fleet colleagues • won the Volunteer Team of the Year Award for our volunteer car service at the East Midlands Charity Awards 2020.

21 Nottinghamshire

During 2020/21 in the Nottinghamshire division we:

• introduced station COVID-19 relief • introduced a COVID-19 lead to ensure a single point of contact for staff and other departments and a coordinated approach to the pandemic response • achieved closer working with the Acute Trusts regarding pathway changes • introduced technician team mentors to assist the clinical support managers • achieved flu vaccination targets • audited ambulance conveyances to Nottingham University Hospitals (NUH) which identified that 70% of conveyances were appropriate. The remaining 30% was made up of 10 patients who could have gone elsewhere, failed pathway attempts & pathway gaps – eg mental health. The results from this audit have been shared at a system level to enable pathway access issues and gaps to be rectified • undertook detailed auditing of ‘Failed & Successful’ pathway reporting. Production of a system-wide report with outcomes of the auditing, information sharing agreements in place to enable data sharing & provider to provider enabled discussions to improve pathway access • established the Sherwood Forest Hospital Foundation Trust (SFHFT) Shared Care Standard Operating Procedure pathway, resulting in 72 avoided ED conveyances for vulnerable care home residents in midst of the global pandemic • assured a number of existing pathways through the governance process, including the NUH Transient Ischaemic Attack (TIA) pathway, which evidenced the new EMAS indication for aspirin in TIA cases and expansion of the pathway into SFHFT • contributed to the Notts Same Day Emergency Care (SDEC) system plans and task and finish groups • identified pathway gaps in urology, resulting in system-wide task and finish groups and mapping/gap analysis exercises • confirmed SFHFT ED conveyances 99% appropriate in NHSE missed opportunities audit (two patients could have gone to an Urgent Treatment Centre, but no alternative available as this sits behind the single front door) • rolled-out Alternative Pathways Ambassador initiative across the division and wider adoption into Lincolnshire and Derbyshire - peer to peer support for identification and use of alternative care pathways • piloted CAT 3 re-triage with NEMS which reduced ‘See and Treat’ and increased ‘Hear and Treat’ activity, ensuring that patients received the most appropriate threshold of care response • delivered a focused Reducing Conveyance week, as part of the project a communications and engagement plan was implemented which enabled staff to feedback to divisional leaders and for the reducing conveyance team to temperature check the outputs of the project • reduced 50 ambulances per year going to EDs in Nottinghamshire without an increase in incidents or a reduction in safety

22 • developed a patient questionnaire for patients we have discharged at home following assessment in March - analysis will be undertaken by the Patient Experience team

In order to support continued oversight of quality at a local level, in January 2021 we introduced a Divisional Scorecard including metrics across all five of the Care Quality Commission domains. This is provided monthly to local commissioners along with more detailed monthly and quarterly narrative reports providing analysis, triangulation and details of actions taken in response.

Care Quality Commission

In July 2019, we were delighted to announce that the Care Quality Commission (CQC) rated us as ‘Good’ overall and ‘Outstanding’ for caring. The change is great progress on our previous rating of ‘requires improvement’ in 2017, and is due to a huge amount of focussed work by colleagues across EMAS.

As part of their inspection, the CQC looked at our vision ‘The Big 3: Respond | Develop | Collaborate’ and said that we had workable plans in place to achieve it. They also said that our staff morale had improved, staff felt supported by management and that we had a strong person-centred culture.

EMAS is fully compliant with the registration requirements of the Care Quality Commission and has arrangements in place for ongoing monitoring of compliance with these requirements and ensuring that actions required by the Care Quality Commission are implemented. We are not resting on our laurels and are committed to continuous improvement with the aim of achieving an overall rating of ‘Outstanding’.

The CQC is not routinely inspecting services during the pandemic period and recovery phase, although they will carry out some focused inspections. The CQC is maintaining contact with providers through usual engagement calls and transitional monitoring arrangements, such as those in place for infection prevention and control.

In August 2020 the CQC met with the Trust virtually following submission of evidence against the Infection Prevention and Control Board Assurance Framework first published by NHS England and NHS Improvement in May 2020. A summary record of the meeting was provided which found that the Board is assured that the Trust has effective infection prevention and control measures in place.

In December 2020 the CQC met with EMAS again virtually following submission of evidence against Key Lines of Enquiry focused on winter/COVID-19 preparedness. The CQC were assured by the plans in place to manage what was anticipated to be a challenging winter period.

EMAS has also contributed to two Provider Collaboration Reviews (PCR) in the Lincolnshire system in July 2020 and in Northamptonshire in October 2020. PCRs are designed to consider how well system partners collaborate to meet the needs of the population. They 23 are designed to facilitate learning and improvement and do not impact Trust ratings. Positive feedback was received following both reviews regarding the role EMAS plays in the wider system.

During 2020/21 the Trust applied for an amendment to its CQC registration to include surgical procedures in recognition of the increasing complexity and clinical scope of activity undertaken by our specialist crews or on our behalf by, for example, air ambulance services. This was approved in January 2021 and our registration status was updated accordingly.

New services and innovation

The introduction into EOC of SystmOne with Telephone Assessment Service (TAS) Version 3.0 embedded into SystmOne in early 2020 has unequivocally supported the clinical hubs response to COVID-19. The clinicians and EOC doctors have been able to review patient records and had a much greater understanding of a patient’s complex history enabling enhanced decision making and supporting patients to alterative care pathways and promoting hospital emergency department avoidance where appropriate.

In April 2020 the ability to have the EMAS EOC Clinical Hub remote working was significantly accelerated in response to the global pandemic, which saw 50% of the EOC clinical workforce with the ability to work remotely from their own home. This ensured throughout the pandemic that there were strong staffing levels as the ability for our colleagues to work safely and support the EMAS response to the prevailing demand.

Also, in April 2020 the EOCs were dispersed across multiple areas at both the Nottingham and Lincoln headquarters, vacated by enabling services colleagues who began working from home, to support social distancing. All desks were fitted with Perspex social distancing screens, and one-way systems were arranged to ensure EMAS followed safety precautions to ensure the areas were COVID secure.

September 2020 saw EMAS become part of a national Category 3 and Category 4 validations pilot with NHS England and NHS Improvement, to produce a nationally agreed set of evidence-based code sets and processes for clinical validation of appropriate lower acuity 999 calls prior to an ambulance dispatch. The pilot looks to: • align the approach already in place for NHS111 • demonstrate effectiveness of clinical assessment within specific cohorts of patients • increase ‘Hear and Treat’ whilst maintaining clinical safety and reducing requirement for ambulance dispatch where alternative clinical advice is available • implement pilots to inform the necessary code-set changes in preparation for winter 2020/21 • address variations in conveyance rates within the C3/C4 categories across ambulance trusts with the aim to provide consistency in process and stabilise conveyance rates • augment the opportunities identified through Pandemic Protocol 36 particularly within the Category 3/Category 4 activity pool.

24 In November 2020 the Clinical Hub gained access to the Child Protection Information System (CP-IS) with a collaborative trust project to enable the Clinical Hub clinicians to see pertinent information in respect to maternity plans and child protection plans supporting yet further enhanced decision making and robust safeguarding measures. This is an ongoing project and we will roll this out to the 999 emergency call handlers at first contact on a 999 line, ensuring yet more safety nets are in place for vulnerable patients.

In January 2021 EMAS has now set up interoperability call passing gateways to every ambulance trust and those with devolved geographic areas (Scotland, Wales, Northern Ireland). This enables rapid passing of 999 calls and the ability to support national 999 call taking ensuring patients across the United Kingdom receive a timely 999 call answer, and to support other services when they are under significant pressure or responding to a major or business continuity incident.

And despite the pandemic we also rolled out the new specialist practitioner role, introduced to provide more advanced clinical care to patients that would have traditionally needed conveyance to hospital for certain procedures. The role has been introduced as part of our Big 3 vision and strategic objectives.

What we have done to improve patient safety

Learning from incidents, experiences and feedback

At EMAS we have an open and honest approach that we promote to our staff; encouraging them to report excellence or poor practice. EMAS has a robust reporting system in place where staff can report issues and be confident that they will be taken seriously. This method of reporting helps us to identify learning opportunities, ensure that we learn from mistakes to reduce the risk of it occurring again or replicate best practice into other areas.

Learning is also identified through investigating untoward incidents, serious incidents and complaints. Other sources are patient surveys, compliments, community events and patient focus groups.

Learning is incorporated into training and development programmes and disseminated through clinical bulletins and regular staff briefings, Learning from Events sessions and communications.

Duty of Candour

EMAS’ priority is to deliver safe, prompt care to our patients. We are committed to openness and will always tell patients if something has gone wrong during their care. We encourage a culture which involves acknowledging, apologising and explaining when things go wrong, conducting thorough investigations and ensuring that lessons learned assist in future incident prevention and providing support for those involved.

25 Serious Incidents (SIs)

Our transparent approach sees us proactively encourage colleagues to report patient safety incidents in line with a mature safety culture. Reporting allows us to analyse what happened to identify and put in place actions to reduce the risk of recurrence. During the year, EMAS identified 38 serious incidents requiring investigation, this compares to 52 in the previous year.

The Trust’s Quality and Governance Committee has looked into the reasons for the significant decrease, which is a result of improved identification and categorisation of incidents, a reduction in delayed responses and improvements in clinical care.

The main category of incidents in 2020/21 relate to the quality of clinical care. This is a change from the previous year when the highest category of SI was delayed response (22 SIs) compared to only one in 2020/21.

A recurring theme has been identified in relation to cardiac arrest management. The roll out of the cardiac arrest strategy in particular the Cardiac Arrest Leader role will mitigate the risk of further recurrence. There have also been three road traffic collision SIs in 2020/21. A deep dive is currently underway and due to report to the Trust’s Quality and Governance Committee in Quarter 1 2021/22. Initial findings indicate that there are no themes or trends, eg weather, time of day, experience of driver.

Learning from Events sessions have been held throughout the year to share learning from SIs and other sources, eg complaints, safeguarding investigations, compliments and audit findings.

The EMAS Trust Board regularly receives an update on the number and type of serious incidents reported. Again supporting our open approach, the Board meeting papers are made available to the public approximately a week before each meeting via www.emas.nhs.uk/about-us/trust-board

Although the national implementation of the revised Patient Safety Incident Response Framework, as part of the NHS Patient Safety Strategy, has been delayed we have continued to evolve our processes to align with the new framework in readiness for adoption when the framework is published. This has included ensuring that we learn from when things go well, not just when they have gone wrong and increasing the extent to which we collaborate with system partners to investigate incidents. During 2020/21 we have jointly presented cases at our internal Learning from Events sessions with Acute Trust colleagues.

Learning from deaths

EMAS is committed to the delivery of prompt, safe patient care. We strive to promote a culture that encourages candour, openness, honesty and learning at all levels. As part of this commitment we implemented the National Guidance on Learning from Deaths 26 (March 2017) and the National Guidance for Ambulance Trusts on Learning from Deaths (July 2019) (https://improvement.nhs.uk/resources/learning-deaths-nhs/) in Quarter 4 2019/20 and have continued to do so quarterly throughout 2020/21.

Each quarter, senior clinicians undertake an initial structured judgement review of the care provided at each phase of the episode of care for a minimum of 40 deaths across a range of categories to determine an overall care score (stage 1). The period of care commences from the time our staff answer the telephone call from the patient, or their representative requesting assistance, to the time we transfer the patient’s care to another healthcare provider, discharge the patient at scene or where clinicians complete Recognition of Life Extinct (ROLE) of the patient.

Where a care score of 1 (very poor) or 2 (poor) is achieved at stage 1 the case proceeds to a stage 2 review by a group of senior clinicians where consensus opinion is agreed regarding whether or not any care concerns were more likely than not to have contributed to the death occurring at the time that it did.

During 2020/21, 218 deaths were reviewed with a focus on cardiac arrest management to support quality improvement work in this area, aligned with our cardiac arrest strategy and quality account priorities. Only two cases achieved an overall care score of 1 or 2 and proceeded to a stage 2 review. No cases were identified where the care concerns were more likely than not to have contributed to the death occurring at the time that it did.

Data in relation to protected characteristics is recorded so that equality analysis can be undertaken. No issues have been identified as a result of this analysis. Rates of recording of ethnicity data have improved significantly throughout the year with consistently greater than 95% of this data now being recorded.

Findings are used to facilitate learning and improve patient care and outcomes, particularly in relation to the care of vulnerable people. The Learning from Deaths report is reviewed by the Quality and Governance Committee on a quarterly basis. The table below shows a summary of learning from the reviews undertaken in 2020/21.

Phase Definition Areas of good practice Areas for improvement 1 Initial • Early identification • None identified management/ of cardiac arrest pre-scene

27 and deployment from EOC • Early intervention with CPR instructions by the emergency medical dispatcher (EMD) • Deployment of a

Lucas device to scene 2 On-scene • Areas of excellent • Completion of care on scene paperwork and identified with full including rationale ALS initiated and when deviating from good compliance trust policy with the • Clinical records need resuscitation care to be precise and bundle include a full • Good compassion rationale when shown with leaving a patient at families of the home, including any deceased health care • Good completion professionals spoken

of ePRF in most to and advice taken cases • Timings on Diagnosis • Excellent care of deaths need to be shown for consistent palliative care end throughout the of life patients clinical record 3 Handover/ • Of those • None identified transfer transported, pre- alerts were made to good standard 4 Discharge • Good liaison with • None identified Coroners officers and police for on

scene diagnosis of death

Prevention of Future Deaths No Prevention of Future Deaths (PFD) reports were received from the Coroner in 2020/21 (compared to four in the previous year).

28 EMAS has however reviewed PFD reports received by other Trusts to assess for relevance and to ensure learning is implemented where appropriate.

Harm Reviews During 2020/21 we introduced regular proactive harm reviews to monitor the impact of both hospital handover delays and resulting delayed community responses. Over 900 cases were reviewed. From the cases reviewed only two cases of potential harm were identified and these have been jointly investigated with the relevant acute Trust.

It is however acknowledged that these delays represent a poor patient experience. It is also recognised that whilst ever delayed handovers and community responses continue to occur the risk of patient harm is present.

Both good practice and learning has been identified from the harm reviews and action plans have been developed in response to these findings. Guidance has been developed through the National Ambulance Service Medical Directors Group to support staff in maximising safety during prolonged handover delays and work continues with commissioners and regulators through the improvement collaborative to reduce handover delays and the resulting impact on operational performance. This includes expansion of Same Day Emergency Care pathways and direct access to specialties.

We have also introduced twice yearly reports analysing the impact of operational performance on the three domains of quality; patient safety, patient experience and clinical effectiveness which are considered at the Trust’s Quality and Governance Committee. This triangulates quality metrics including patient safety incidents (including serious incidents), patient experience measures (including complaints and compliments) and clinical indicators (including the National Ambulance Clinical Outcomes) with activity, acuity and performance.

From the data analysed there does not appear to be a strong correlation between patient safety indicators, patient experience or clinical indicators and poor operational performance, high activity and acuity.

The absence of direct correlation is likely to be due to the actions that we take to ensure that when resources are limited these are focussed on the highest acuity calls and that patient and partner expectations are managed during such times.

This does not mean however that the risks to these indicators are not increased when performance is not achieved. Therefore, it is imperative that we continue to work collaboratively with system partners to improve our operational performance and hence the quality of care that we can provide. We must also continue to monitor and mitigate risks to quality associated with performance. Freedom to Speak Up

The purpose of the Freedom to Speak Up (Raising Concerns) policy is to:

29 • Provide employees, agency workers, bank staff, volunteers and contractors with a clear and confidential process to raise concerns about malpractice which involves a danger to patients, the public or colleagues, an issue relating to professional misconduct or financial malpractice. • To create and encourage a culture of openness, where individuals who wish to raise concerns, feel confident enough to speak out and trust that EMAS will act on those concerns.

Staff can raise concerns either verbally, in writing or by email to any manager, the Freedom to Speak Up Guardian, the Executive Lead (who is the Director of Quality Improvement and Patient Safety) or the Non-Executive Lead for Freedom to Speak Up (Vijay Sharma). They can also use the generic email address [email protected].

Staff can raise concerns anonymously if they wish. Concerns are logged and an investigating manager is assigned to each case. Feedback is provided to individuals who raise concerns, provided this is not done anonymously. A record is kept of any action taken in response to a concern.

All staff are made aware of the policy via induction and reminded of this via the internal newsletter Enews. In November 2020 an online FTSU training module was launched on the Totara system. This will form part of mandatory training from April 2021 with updates required every three years, but completion of the module has been encouraged since its launch. To date over 400 staff have completed the module despite this still being voluntary.

We have seen an increase in FTSU referrals during 2020/21 with 18 referrals having been made compared to 11 for the whole of 2019/20. This along with a reduction in the percentage of staff who wish to raise their concerns anonymously from over 90% in 2019/20 to just over 20% in 2020/21 is a sign that our reporting and learning culture is improving.

In 2020/21 we introduced a feedback form to capture staff experience of using the FTSU process and this has been overwhelmingly positive with all those who have responded stating that they would use the process again and recommend it to their colleagues.

30

I was supported It was a with my initial friend/colleague concern/ question Thank you for that signposted me to FTSU and I as well as all your receiving support support- it has would highly I didn’t expect but been a positive recommend the gratefully experience. same to another colleague. received.

A recurring theme in relation to management behaviours was identified from referrals during the year. The FTSU Guardian has worked closely with the Deputy Director of Human Resources and Divisional Leadership Teams to address any issues and support leadership development.

What we have done to improve patient experience and engagement

EMAS Patient Voice Forum

EMAS Patient Voice Forum is a group of volunteers chaired by the Deputy Director of Safety and Patient Experience; supported by patient representative and Vice-Chair John Crouch. John also attends our Quality and Governance Committee on a quarterly basis to provide an update on the work of the group and to provide a patient perspective on quality at the Trust.

The Patient Voice Forum and Sub-Groups continue to meet via Microsoft Teams with the majority of members joining for the meetings. Workplans for 2021/2022 are being drafted to include virtual activities and inclusion of projects Trust wide, such as an updated non- conveyance, health advice leaflet and media release feedback.

Members of the Patient Voice submitted an application for an award (of up to £1,500) through the East Midlands Academic Health Science Network (EMAHSN) in 2020. The award was aimed at Patient and Public Involvement Groups in the East Midlands for the promotion of patient, carer and public involvement in healthcare delivery or health research. EMAS were awarded the £1,000 in March 2021 and are now looking at ways for the groups to invest in patient and public involvement.

The Complaints and Media review was held virtually on 15 September 2020. The meeting was well attended by 11 members from both the central, Nottinghamshire and Derbyshire groups; the largest attendance of any of the review meetings. The group reviewed three press releases provided by the Communications team, a formal complaint and a service to service concern, the latter two of which were anonymised for this purpose and shared via Microsoft Teams on the day. The group interacted well and there was a great deal of lively discussion and debate about various aspects of the process within the cases. The

31 group felt, that whilst the process was fairly time consuming, it was very thorough and worthwhile and have suggested that we hold three such meetings per year rather than the current two.

The Patient Voice members also had an active role in providing feedback on the Patient Advice Leaflet produced by the Trust for those patients who are left at home. The feedback was well received and incorporated into the leaflet. The members look forward to the next project with the Clinical Directorate.

EMAS has gained two new members for the newest Sub Group of Patient Voice in Lincolnshire, although small in size currently with three members, it is positive that this group has been created during the pandemic and is being established.

Compliments

When the colleague(s) can be identified by the information provided, they are thanked personally by the relevant general manager/Director of Quality Improvement and Patient Safety in the form of a letter which accompanies a copy of the patient feedback.

We are grateful to the patients and their relatives who have been happy to share their experiences, via our social media channels, and with local and national media. We are tremendously proud to be able to promote the achievements of our colleagues in this way and it always gives a real boost to morale.

During 2020/21, we received 1,155 expressions of appreciation from patients or members of the public, compared to 1,230 in the previous year. We also received 1,481 compliments via the internal compliments system – Learning from Excellence compared to 594 in 2019/20. This makes the total number of compliments both internal and external 2,636 compared to 1,805 in the previous year, an increase of 831.

Formal Complaints (FC)

During 2020/21 EMAS identified 58 formal complaints requiring investigation compared to 132 in 2019/20, a reduction of 74, of which: • 46 related to our A&E services • 1 related to Patient Transport Services • 11 were trust wide

The three general themes related to: • attitude of staff • quality of care • delayed response to the patient

These are the same themes as those identified in the previous year, although delayed response was the highest category of complaint in the previous year whereas it is the third highest this year. These themes are consistent across the divisions.

32 External compliments and formal complaints received per county during 2020/21 were as follows:

County Compliments Formal complaints Derbyshire 225 7 Derbyshire PTS 10 1 Leicestershire and Rutland 205 3 Lincolnshire 218 8 Northamptonshire 159 1 Northamptonshire PTS 2 0 Nottinghamshire 248 9 EOC 23 18 HART 0 0 Trust-wide issue 65 11 Total 1155 58

From March 2020, the team continue to have weekly team conference calls which are being held via Microsoft Teams to discuss priority of cases. Monthly team meetings also continue via Microsoft Teams.

Continued proactive actions have been taken to support the members of the public: • The Patient Advice and Liaison Service (PALS) telephone line has been adapted to reflect the support being provided to the wider NHS, apologies are given on the message. • The Team also have a similar message on their email signatures. • Updates are being provided over the telephone and updated in Ulysses as much as practically possible. • Communication on the EMAS website to reiterate the delays within the team. • Updating on-going PALS concerns and keeping in touch with the complainant.

From July 2020, a patient experience officer has been seconded to the Investigation Team to support their current workload. This is an excellent development opportunity for the member of staff to learn new skills and also share skills from their previous role. The internal flex of resources is great for future business continuity. As the number of SIs is currently low the Investigation Team are currently supporting the Patient Experience team with service to service enquiries which again will promote the sharing of skills and knowledge and build resilience for the future.

33 In line with other Trusts across the NHS, the deadlines for responding to patients and their families was extended in March 2021 to 60 working days, rather than 30. This was to ensure that the concerns and complaints process is given the time for a quality investigation and response. Our divisional colleagues have been extremely busy during the course of the pandemic and an extended timeframe was required to ensure time is allowed for review and identification of learning points across the Trust.

General approaches to learning from serious incidents and formal complaints include:

• communication of key learning points through education, training, communication and awareness • clinical case reviews and reflection of the practice by individuals • amendment to policies, procedures and practices • themes being reviewed by our Incident Review Group via Microsoft Teams which consists of multi-disciplinary membership • shared learning across the Trust incorporated in Learning from Events sessions via Microsoft Teams. In the past year Learning from Events sessions have covered a wide range of subjects including -

• Paediatric Cardiac Arrest Management • The Deteriorating Patient • Chemical, biological, radiological and nuclear (CBRN) and Novichok • End of Life Care and ReSPECT forms • Obstetric Emergencies • Domestic Abuse • Sepsis

Ombudsman requests

During the first phase of the pandemic the Parliamentary Health Service Ombudsman (PHSO) paused investigation of complaints. Since the pause has been lifted the Trust has been made aware of six cases that the PHSO are investigating. These are detailed below. As a result of the pause in investigation two of the cases remain open and under investigation. Four cases have been closed with no further action for EMAS. Five cases were referred in the previous year. Two of which were withdrawn, one was not upheld, one was partially upheld, and one has been carried over to 2020/21 due to the pause.

Month Case reference and Action taken Outcome received summary June 2020 FC/19/051 Information supplied No further action – Case closed July 2020 SI/2017/28009 Information supplied No further action – Case closed July 2020 PALS/19/0989 Information supplied No further action – Case closed July 2020 PALS/16/0280 Information supplied No further action – Case closed November PALS/18/0634 Information supplied Awaiting final views 2020 from PHSO January FC/17/127 Information supplied Awaiting final views 2021 from PHSO 34 Patient stories

EMAS captures patients’ experience in a variety of ways. One way is by inviting patients and carers into our Trust Board meetings to tell their story. During 2020/21 all Trust Board meetings have been held virtually as a result of the COVID-19 pandemic restrictions. Patient stories will resume in May 2021.

Extracts from messages of thanks during 2020/21

Derbyshire

Mr T would like to pass on his thanks to Diane, Jamie and Bethany after they helped his son earlier in January.

He said: "The speed at which the ambulance was able to attend and the amazing professionalism of the call handler, who was able to calm and make sense of my partner who rang 999 whilst being hysterical about the situation, is outstanding.

"Keep up the amazing job you all do. Even though I hope we never have to see you in the same setting again. It was an absolute pleasure to see you yesterday. Thank you again."

Ms B would like to thank Keiran and James after they attended her in March.

She said: "They were really supportive, kind, caring and had a wonderful sense of humour. They had to locate me on muddy stony terrain with a support vehicle on hand. A real credit to this country and deserve respect and certainly better treatment than they often receive. Thank you lads, you made an old lady happy and I am recovering well."

Enabling Services

A colleague from the Nottinghamshire Resource Management team sent a lovely thank you to our Communications team.

They said: "I just want to say a big ‘Thank you’ for all the additional workload this virus is bringing to the ‘EMAS Comms’ team.

“I would like you to know that all the extra workload with the additional communications isn’t going unnoticed. It is noticed and very much appreciated. Don’t forget to look after yourselves as well as looking after us all."

Angela would like to thank Head of Infection Prevention and Control (IPC) Elizabeth for incredible guidance and work during the global pandemic.

35 She said: "Since she started with EMAS Liz has been an amazing help in guiding Non- emergency Patient Transport Services and myself through the COVID pandemic, ensuring we are up to date with all of our IPC requirements.

"Liz has always been really approachable and has gone above and beyond to find information out for us. She is also managing the COVID outbreaks in a supportive way while ensuring that all areas are providing the information required for our external requirements.

"Liz shows all of the EMAS values and is a great asset to our team. Thank you personally from me as well for the help you have given. It has made my role more straight forward."

Fleet, Supply, Ambulance Support and Logistics

A clinical operations manager at Notts South Division has passed on his thanks to Fleet Services

He said: "I would like to say that the guys at workshops have been fantastic today in helping us get vehicles turned around so quickly."

Jennifer and the North Lincolnshire Clinical Operations Manager and Clinical Support Manager team would like to thank David, John, Colin, Stephen and Iain from the Scunthorpe Vehicle Make Ready team. They said:

"We would like to say a massive thank you for all you have done over the past few weeks behind the scenes.

"Stocking and cleaning the vehicles and ensuring PPE and equipment is in working order and to hand.

"You have worked extremely hard in these trying times and it has been very much appreciated. Well done and thank you, you are all stars!"

Mr B, a community first responder (CFR) colleague, would like to thank the Medical Devices Engineering (MDE) team for servicing their CFR kit in November.

He said: "I'd like to thank you all at MDE for the fantastic service you've provided this week.

"I know how busy you all are at the best of times but under the current pandemic conditions the demand on you must be immense. You all did a great job and have our gratitude and admiration."

36 Emergency Operations Centre

Mrs C would like to thank Jade who was off-duty at the time but stopped to help when Mrs C's house was on fire.

She said: "We have been relocated to another property due to damage caused by the fire and we are all doing well."

A technician from Oakham, has thanked Ashley, Dan and Rachel, from the Leicestershire desk at our Emergency Operations Centre, after they provided support following a difficult job in May.

She said: "I don't think EOC often get thanked enough and on this occasion, they deserve a lot of credit. They truly went above and beyond to help myself and my crew mate out."

Leicestershire and Rutland

Ms S has thanked Mark, Caitlin, Daniel, Julie and Charlotte after they attended her dad in December.

She said: "I just wanted to thank everyone involved. Me and my mum are so grateful for everything they did.

"You all do a superb job and it was proved to me that afternoon. A big thank you to everyone involved. Stay strong and stay safe."

Ms G would like to thank Lee, Dylon and Tracy for attending her father-in-law in May.

She said: "I would like to express our family's gratitude and huge thanks to the crew that supported us. They were amazing and words cannot express how supportive they were with us all. Nothing was too much trouble and they did not rush anything, everything was done at our pace."

Lincolnshire

Ms G would like to thank Carol and Kathleen for helping her mum back in December last year.

She said: "Two ladies from Stamford Ambulance Station were called to attend my mother on Saturday 5 December.

"It was unfortunately just minutes too late as my mother passed away as your paramedics arrived.

"I would like to say how kind and caring they were at the time and how much it was appreciated at a difficult time."

Mrs K would like to thank Lukasz and Les.

37 She said: "They were brilliant on finding that my husband had no care plan in place and they set about getting it for me.

"It has taken me five long months to get care for him.

"He now has carers and a care plan thanks to them."

Northamptonshire

Mr T has thanked Dean and Bradley after they attended one of his friends in December.

He said: "The two paramedics who attended were fantastic. Not only were they highly skilled and professional, but they showed exceptional humility."

Mr B has thanked Nicola and Steven after they attended him in October.

He said: "A massive thank you to the crew. They were absolutely phenomenal. Down to earth, brilliant and humorous. They were so calming and the family feel they couldn't have asked for two better paramedics! They were amazing!"

Nottinghamshire

Ms E would like to thank Laurel and Anthony for helping her in February.

She said: "I just wanted to let them know how much we appreciated their help and support.

"Although I was reluctant to go in for assessment, they were right to persuade me.

"You were both very professional, knowledgeable and a credit to the service."

Mr M would like to thank Natasha and Peter, Christopher and Michael.

She said: "We would like to commend this crew who were kind, professional, thoughtful, and demonstrated a real compassion towards our resident.

"I am sure they must be under considerable pressure right now but you wouldn't have known it by their calm and considered approach."

Patient Transport Service

Mr B, a fellow colleague in EMAS, would like to thank Alex and Wesley for bringing him home in August.

38 He said: "I was discharged and was brought home by the wonderful PTS crew. Their care was exceptional and once home they went out of their way to get me comfortable. My sincere thanks to all involved.

"It is a pleasure to know that we have staff of this standard working for EMAS."

Mr and Mrs L would like to thank the Patient Transport Services team for providing transport to operations.

They said: "Thank you all of the staff involved in providing transport from Matlock to all of his eye operations. Without their kind, courteous and professional service he would not have been able to have this done."

Corporate communications and engagement

For obvious reasons and despite the challenges they brought, and the pace at which we needed to work, during the year communications and engagement has improved as we’ve had to adapt quickly; we have used platforms and live sessions to interact with staff, stakeholders and the public.

Across the organisation our representatives have played their part at Local Resilience Forums, responding to the pandemic and other unrelated issues and crisis, ensuring a voice around the table and that key messages and information is shared consistently and on a timely basis internally and externally.

The pandemic meant we were not able to arrange patient reunions with the crews and colleagues who went to their aid, or bravery award, school or community group presentations; we look forward to the day when we can return. In the meantime, we have continued to listen to patient and relatives’ stories and experiences, with teams across the service capturing their feedback and sharing it with colleagues, eg via the new Learning from Events video conference sessions led by our Quality and Clinical Teams to support continuous learning from scenarios where we could or should have done better, and when a good service and outstanding care was provided.

We held our Annual General Meeting in September via Microsoft Teams and were delighted to have over 100 people join the live presentation and question and answer session, with many watching the video recording after the event: https://www.youtube.com/watch?v=ZGMCqtCxzlo&t=14s

Unlike previous years, due to lockdown, we were unable to hold face-to-face training sessions to teach cardiopulmonary resuscitation (CPR) in schools and the community for Restart a Heart Day; instead we broadcast a live CPR demonstration via Facebook and promoted the film on our social media networks, so people could still take part and refresh their skills.

With a greater reliance of digital communications and following the change to governmental Web Content Accessibility Guidelines (WCAG), the Communications team commissioned an audit of the EMAS public website to assess our accessibility compliance. We were found to be partially compliant; work has been carried out to ensure EMAS is now compliant up to Level AA of WCAG 2.1, with more details and assurance published on our website. 39

Staff communication and engagement

COVID-19 restrictions meant our usual EMAS Conversation Café quarterly staff engagement tours across the region could not take place. In response, we launched a new monthly (at times, fortnightly) Virtual Conversation Café. If their day allows, staff are invited to join members of our Executive team over a cuppa for a video conference update and live question and answer session. Each session is recorded, and the video and a summary transcript are shared via our weekly staff and volunteer magazine for those not able to join live. During 2020/21, seventeen Virtual Conversation Café sessions were held. The topic is determined by what’s important for staff at that time. For example, during lockdown and the peak waves, our sessions focussed on the COVID-19 virus, infection prevention and control, and personal protective equipment, and the vaccination programme. During an early café our Medical Director performed live the new COVID-19 Lateral Flow Device test so colleagues could be assured it’s a straightforward, safe process. Other sessions focussed on career progression and education opportunities, mental health awareness and staff support, learning from events and freedom to speak up, and we had guest panel members from Derbyshire Healthcare United to talk about, and answer questions on the NHS111 service they provide.

The change we’ve all experienced during the year has been considerable, and it was encouraging to see the EMAS and personal values shine through the staff responses given via our Restoration, Recovery and Reset survey in June 2020. To share the reflections, our Communications team worked with colleagues to create new features, helping us share how the pandemic has impacted on individuals in different ways; it’s important, as part of our developing culture, that we take time to reflect and understand what it has meant for people in our service. The thirteen ‘In My Shoes’ features written during 2020/21, were also published on our website and social media networks, prompting a swell of public compliments and positive reflections on the contributions our teams have made, which in turn boosts staff morale.

Enews, our weekly staff and volunteer digital magazine, continues to receive strong readership rates, and via the internal survey in June, was said by staff to be the number one place to go for reliable updates and information.

We continue to produce and publish Big 3 animations to bring our EMAS vision and strategic objectives to life and encourage staff and stakeholders to ‘get involved and make things happen’. The latest in our series featured our Medical Director and a member of our new Specialist Practitioner team: https://www.youtube.com/watch?v=3yJRgKiAFFs

Social media and media engagement

The Communications team engages seven-days a week with large audiences via EMAS corporate social media accounts on Twitter, Facebook and YouTube. To enhance engagement with wider audiences, whilst increasing the promotion of public health messages and our EMAZING achievements, the team launched a new EMAS Instagram account in July 2020.

The way we work with local, regional and national broadcast, print and online media to promote stories and news of importance to our public and staff has had to change in response to the pandemic, however we continue to engage positively with journalists,

40 taking part in broadcast and print interviews, and many of our website news stories have been reported via media outlets.

During 2020/21 we researched, wrote and published 82 website feature articles and news stories to shine the light on the work of our colleagues and volunteers. We are grateful to the patients, relatives, carers and staff who allow us to share their stories – their contributions support our public education work regarding the right use of 999. Here are a few examples of some of the stories promoted during 2019/2020:

• Fire service colleagues to support EMAS with COVID-19 response: https://www.emas.nhs.uk/news/latest-news/2020-news/fire-service-colleagues-to- support-emas-with-covid-19-response

• Thank you to all our volunteers who are gong above and beyond to help with COVID- 19: https://www.emas.nhs.uk/news/latest-news/2020-news/thank-you-to-all-our- volunteers-who-are-going-above-and-beyond-to-help-with-covid-19

• Celebrating the nurses of EMAS – Karl Anderson: https://www.emas.nhs.uk/news/latest-news/2020-news/celebrating-the-nurses-of-emas- karl-anderson

• Man sentenced to 20 weeks in prison after assaulting our ambulance crew by spitting at them: https://www.emas.nhs.uk/news/latest-news/2020-news/man-sentenced-to-20- weeks-in-prison-after-assaulting-our-ambulance-crew-by-spitting-at-them

• Coalville tri-service station officially opens: https://www.emas.nhs.uk/news/latest- news/2020-news/coalville-tri-service-station-officially-opens

• In My Shoes: Paramedic Terry Thompson shares his experience of COVID-19: https://www.emas.nhs.uk/news/latest-news/2020-news/in-my-shoes-paramedic-terry- thompson-shares-his-experience-of-covid-19

• EMAS prepared and ready for action this winter: https://www.emas.nhs.uk/news/latest- news/2020-news/east-midlands-ambulance-service-prepared-and-ready-for-action-this- winter

• Medical student lending helping hand to EMAS colleagues on Christmas Day: https://www.emas.nhs.uk/news/latest-news/2020-news/medical-student-lending- helping-hand-to-emas-colleagues-on-christmas-day

• A tribute to Tony Chadbourne: https://www.emas.nhs.uk/news/latest-news/2020- news/a-tribute-to-tony-chadbourne

• New specialist practitioner team helps reduce hospital admissions: https://www.emas.nhs.uk/news/latest-news/2021-news/new-specialist-practitioner- team-helps-reduce-hospital-admissions

• Ambulance crew in Scunthorpe prevent patient from falling foul of fraud: https://www.emas.nhs.uk/news/latest-news/2021-news/ambulance-crew-in-scunthorpe- prevent-patient-from-falling-foul-of-fraud

41 • Ambulance service contributes to the Hope Orchard: https://www.emas.nhs.uk/news/latest-news/2021-news/ambulance-service-contributes- to-the-hope-orchard

• Urgent Care Transport Service celebrates third anniversary: https://www.emas.nhs.uk/news/latest-news/2021-news/urgent-care-transport-service- celebrates-third-anniversary/

All published stories can be found on the News page of our website at www.emas.nhs.uk

Equality, diversity and inclusion

Equality, diversity, inclusion and human rights encompass all our aims, objectives and actions addressing inequalities and promoting diversity in healthcare and employment. The key principle of diversity and inclusion is that it belongs to everyone and that every individual has the right to be treated with respect and dignity as aligned to the EMAS core values.

We are committed to ensuring that our services are not discriminatory, enabling equality of access and provision, and meet legal requirements under the Equality Act 2010 and the specific elements of the Public-Sector Equality Duty.

The Equality Delivery System 2 (EDS2) is used to ensure that service priorities are influenced and set by the health needs of all our local and regional communities through consultation, equality monitoring and partnership working.

Key achievements from the Equality, Diversity and Inclusion team, during 2020/21 include the following:

• The Equality, Diversity and Inclusion Strategy 2020-2023 was approved by the Trust Board in August 2020. • An Equality, Diversity and Inclusion Training Plan for 2021-2022 has been developed and incudes a new series of workshops relating to Accountability, Reputation and Professionalism and Equality Impact Assessment training for all managers and policy leads. • Delivering bi-monthly cultural competency workshops to the Trust’s Clinical Education teams to provide continuous professional development. • Continuation of the Equality Everyday Induction programme for new starters within the Trust. • The introduction of equality briefing papers to educate and inform all staff within the Trust on key equality, diversity and inclusion matters such as Subtle Racism and Microaggressions in the workplace, Civility and Respect and Bystander Syndrome. • The Workforce Resourcing and Governance Group formally approved the Equality Impact Assessment policy. The aim of the policy is to ensure that due regard to the requirements of the Public-Sector Equality Duty are observed when developing and reviewing policies, procedures, strategies and introducing new services. • A full review of the Trust’s compliance against the Accessible Information Standard was undertaken and an action plan developed to address areas identified for improvement. The Equality, Diversity and Inclusion Team have worked in partnership with divisional leads throughout the Trust, to ensure compliance is maintained. • Providing continued support, advice and guidance to developing the Trusts Black Asian Minority Ethnic (BAME) and Lesbian Gay Bisexual Transgender Plus (LGBT+) staff networks and working closely with the respective network chairs to establish clear terms of reference, objectives and outcomes.

42 • Implementation of a ‘Reverse Mentoring Scheme’ pilot with members of the Executive Management Team and BAME Network members. The aim of the scheme is to improve senior leaders’ knowledge and understanding of the issues that impact on BAME staff members in the workplace and service users when receiving clinical care. • Maintaining a partnership with the Business Disability Forum leading to increased scrutiny of the Trust’s internal Human Resources processes and creating inclusivity within the working environment.

The Trusts Annual Equality, Diversity and Inclusion reports in relation to the Workforce Race Equality Standard (WRES) and Workforce Disability Equality Standard (WDES) are published on our website and provide further detail.

43 Part Three: Looking forward - what we want to do better in 2021/22

This part of the quality account looks forward and describes the plans we have to ensure that we are continually improving the quality of our services.

Our quality improvement strategy

We launched our new Quality Improvement Strategy 2020-2025 in September 2020 following a period of engagement with staff, patients, the public and wider stakeholders and approval by our Trust Board.

Our vision

Quality is embedded in everything we do; we assure, we learn, we improve, and we innovate, we are empowered to collaborate in delivering high quality services at all times.

Our aim

The aim of this Quality Improvement Strategy is to develop a well led culture of continuous improvement, supported by robust systems and processes and organisational learning, to ensure our services are person centred, clinically effective, responsive to the needs of the populations we serve, delivering a positive experience and are safe for our staff and patients all the time.

Having this new strategy provides us with the framework to deliver services that are the highest quality.

Our objectives

44 C To ensure our services are Caring and Compassionate

R To ensure our services are Responsive to peoples’ individual needs

E To ensure our services are Effective

W To ensure our services are Well led

S To ensure our services are Safe

We identified priority areas and year one actions for each of the objectives.

Appendix 1 provides an update on the actions identified for year one against the priorities to deliver the objectives across the five domains of quality. End of year one quality and improvement metrics data is also shown, comparing this to the 2019/20 baseline. Where end of year data was not available at the time of writing, most recent data is shown, and the time period referred to is indicated.

Despite the considerable challenges presented by COVID-19 during year one of the strategy significant progress has still been made in delivering the identified actions and this is reflected in the improvement seen in the majority (44 out of 58 or 76%) of the quality and improvement metrics during the last year.

Where improvements have not been made these are in some instances due to the impact of COVID-19 on ways of working for example on scene times and post-handover times have increased which is in a large part due to the requirements for donning and doffing personal protective equipment and increased cleaning of vehicles. Staff appraisal and compliance with statutory and mandatory training has also deteriorated due to the additional pressures of COVID-19 making abstraction for training difficult without compromising operational performance and resulting quality of care.

As the strategy was fundamentally about improving the learning culture of the organisation it is particularly pleasing to note that all of the NHS Staff Survey questions monitored as part of the strategy have improved on the previous year.

It is proposed that year two is used as a consolidation year to fully embed the improvements made in year one and enable the opportunity to deliver the small number of outstanding actions that we were not able to deliver in year one. The proposed priority actions for year two are also outlined in Appendix 1.

Consultation has taken place with staff, patients and stakeholders during Quarter 4 of 2020/21 and this approach has been widely supported.

45 Quality priorities for 2020/21

At EMAS we are working hard to bring about significant improvements to the services we provide. We actively listen to our colleagues, patients and stakeholders to act on things that did not go well, and those that had a good outcome, to learn from and reflect on the services we provide.

Priority 1: We will improve the way in which we listen to and use feedback from our patients, carers and families to continually improve our services. We will do this by expanding our patient voice groups and ambassador roles in terms of both numbers and diversity, Caring implementing revised patient feedback for ambulance services and developing a metric to capture compassion, kindness, dignity and respect in action. (carried over from 2020/21)

Lead: Director of Quality Improvement and Patient Safety

Priority 2: We will continue to promote the safe and appropriate use of alternatives to ED by ensuring that our staff have the necessary knowledge, skills, experience and confidence to do so. This will include Responsive ensuring that staff have digital access to shared records and to senior clinical support where required.

Lead: Medical Director Priority 3: We will improve our performance against the nationally reported Ambulance System Indicators and Clinical Outcomes, with a particular focus on cardiac arrest. We will do this through a robust Effective audit programme, effective clinical leadership, sharing learning and implementing improvement strategies. (carried over from 2020/21)

Lead: Medical Director Priority 4: We will continue to learn from when things go well as well as when they go wrong, ensuring that learning is shared both internally and externally to improve the quality of care we provide to our patients. We will work collaboratively with partners to identify and Well Led mitigate risks across the system and implement the Patient Safety Incident Response Framework once published.

Lead: Director of Quality Improvement and Patient Safety Priority 5: We will improve the timeliness of managing safeguarding referrals raised by our staff by fully automating the referrals process Safe ensuring that relevant third parties are alerted in real-time.

Lead: Director of Quality Improvement and Patient Safety

We are committed to continuous quality improvement and believe that our Quality Improvement Strategy and the priorities identified in this Quality Account will support our

46 journey to outstanding; by ensuring that we focus on quality improvement not just quality assurance.

We are committed to continuing to learn from our response to the COVID-19 pandemic and in the process of recovery and restoration to ensuring that the positive impacts that were seen during the pandemic response are taken forward. This will ensure that the hard work and sacrifices made will not have been in vain and that the service we provide in the post COVID era is even higher quality than that provided before.

We would like to place on record our thanks to all of our staff and system partners for their hard work and dedication in ensuring that we continue to provide high quality, compassionate services for our patients and continued support during our improvement journey.

47 Appendix 1 – Quality Improvement Strategy Year One Progress and Year Two Priorities

Objective Priorities To ensure 1. Listen to our patients, carers and families and use feedback to continually improve our services our services 2. Everyone (staff and patients) are treated with compassion, kindness, dignity and respect

are caring 3. Work in partnership with our patients, carers and families and voluntary organisations to improve our services

Caring How will we achieve this? • Expand patient voice groups in terms of diversity of membership and geographical representation, increase

ambassador roles, pilot young person’s engagement • Development of a metric to capture compassion, kindness, dignity and respect in action • Implement new patient feedback for ambulance services • Deliver quality champions training • Capture meaningful patient and staff stories and utilise these to develop and improve services • Undertake thematic analysis of patient complaints and feedback to identify areas for focus and improvement

Actions (year 1) Actions • EMAS representatives at local, regional and national groups, influencing developments What will success look and feel like?

• Patient voice groups in place in all geographic regions with membership reflective of the diverse populations, increased number of ambassadors and evidence of engagement with young people • Metric in place to capture compassion, kindness and dignity and respect in action, baseline established • New patient feedback for ambulance services regularly reported in the Integrated Quality Report

• Records of attendance and champions training • Thematic analysis from complaints and patient feedback and patient stories triangulated and analysed with other sources of quality information and reported in the Quarterly Integrated Quality Report • Improvement log ‘you said, we did’ demonstrating how patient feedback has informed service improvement

Evidence • Patients feel confident about using our services and we feel we are providing an excellent patient experience What progress has been made? 48 • Existing patient voice groups’ membership expanded, new group established in Lincolnshire. Virtual meetings held throughout pandemic • Work on metric development put on hold during pandemic response • Work on new patient feedback for ambulance service put on hold during pandemic response • Quality Champion training on hold during pandemic response

• Patient experience information and triangulation included in Integrated Quality Report, patient story template developed to ensure consistency across ambulance sector • Improvement log maintained

EndYr1 • Compliments and positive feedback continue to exceed complaints • Continue to expand membership and geographical coverage of the Patient Voice Groups to ensure that they are reflective of the diverse populations we serve, increase number of ambassadors and evidence engagement with

young people, involvement in Local Maternity System Voices Groups

• Develop a metric to capture compassion, kindness and dignity and respect in action to establish a baseline • Develop and plan implementation of quality improvement champions training • Continue to undertake thematic analysis from complaints, patient feedback and patient stories triangulating and analyzing this with other sources of quality information and report in the Quarterly Integrated Quality Report

Yr2Actions • Maintain an improvement log ‘you said, we did’ demonstrating how patient feedback has informed improvement Ref Metric Standard 2019/20 Baseline 2020/21 Direction of End Yr1 travel C1 Patient Advice and Liaison Service contacts per 1,000 n/a 1.70 1.63* ↓ improving incidents C2 Formal complaints per 1,000 incidents n/a 0.15 0.06* ↓ improving C3 Service to Service concerns per 1,000 incidents n/a 0.74 0.86* ↑ deteriorating C4 MP concerns per 1,000 incidents n/a 0.03 0.02* ↓ improving C5 Compliments per 1,000 incidents (external) n/a 1.42 1.38 ↓ deteriorating C6 Excellence reports per 1,000 incidents (internal) n/a 0.69 1.77 ↑ improving Ref Indicator 2019/20 2020/21 Direction of Improvement Baseline End Yr1 travel Expectation CI1 % of staff responding positively to the NHS Staff 62.6% 67.0% ↑ improving improving year on Survey Q18a year and in top 49 CI2 % of staff responding positively to the NHS Staff 67.0% 68.0% ↑ improving quartile for sector Survey Q18b by end year 5 CI3 % of staff responding positively to the NHS Staff 70.7% 77.0% ↑ improving Survey Q18d CI4 Cases upheld by the Parliamentary Health Service 1 partially 4 no action; 2 tbc reducing year on Ombudsman **one case from February 2020 not concluded upheld** outstanding year and zero by at time of writing so this may change end year 5 CI5 Ratio of external compliments received to formal 9.5:1 19.9:1 ↑ improving increasing year on complaints year *data as at 9 March 2021

50 Objective Priorities To ensure our 1. Implement a meaningful system to monitor the impact of operational performance on the domains of services are quality responsive to 2. Work in collaboration with our system partners to achieve continuous improvement against the peoples’ needs System Indicators as part of the National Ambulance Quality Indicators (NAQIs)

Responsive 3. Optimisation of opportunities to support personalization of care How will we achieve this? • Implement regular reporting of analysis to assess the impact of operational performance on the domains of quality • Provide regular reports to our commissioners identifying gaps in alternative pathways to support commissioning

decisions • Rapid improvement methodologies training to support service improvement reviews • EMAS involvement in the NHSEngland/Improvement collaborative to reduce hospital handover delays • Analyse and address variation in operational efficiency and develop plans to address this

Actions (year 1) Actions What will success look and feel like?

• Impact of operational performance on quality reports received regularly by the Quality and Governance Committee • Pathway reports shared with commissioners and EMAS involved in discussions about pathway development • Rapid improvement methodology training records of attendance, completed service improvement reviews • Actions arising from the NHS England/Improvement collaborative, eg development of escalation processes • Action plans in place with evidence of progress to address variation in operational performance • Patients feel they are receiving a timely response and we feel satisfied with the standard of care we are delivering

Evidence

51 What progress has been made?

• Six monthly impact reports received by Quality and Governance Committee • Pathway reports (including focused work on Mental Health pathways) shared with commissioners and joint pathway work undertaken, pathway leads in post in some counties, safe discharge on scene workstream established as part of Trust wide transformation programme, pathway tab on iEMAS App to enable staff to identify suitable pathways • Rapid improvement training put on hold during pandemic response • Trust actively engaged in hospital handover improvement collaborative, NHSE/I escalation policy implemented, work continues to improve direct access e.g. the Same Day Emergency Care (SDEC) and specialties • Divisional scorecards now embedded and used in Performance Management Reviews (PMRs), operational efficiency workstream established as part of Trust wide transformation programme

• Improved response times, less complaints and incidents (including serious incidents) associated with delayed response

EndYr1 • Continue to present impact of operational performance on quality reports to the Quality and Governance Committee • Continue to share pathway reports with commissioners and EMAS involvement in discussions about pathway development • Develop and plan implementation of training on rapid improvement methodology • Continue to participate in the NHS England/Improvement collaborative to minimise hospital handover delays • Continue to develop action plans to address variation in operational performance, monitor via Performance Management Reviews (PMRs) and operational efficiency workstream

Yr2Actions Ref Metric Standard 2019/20 Baseline 2020/21 Direction of End Yr1 travel

52 R1 Category 1 (mean) 00:07:00 00:07:41 00:07:13 ↓ improving R2 Category 1 (90th percentile) 00:15:00 00:17:14 00:12:46 ↓ improving R3 Category 2 (mean) 00:18:00 00:30:31 00:23:40 ↓ improving R4 Category 2 (90th percentile) 00:40:00 01:16:11 00:49:10 ↓ improving R5 Category 3 (90th percentile) 02:00:00 04:34:50 02:37:38 ↓ improving R6 Category 4 (90th percentile) 03:00:00 03:54:50 02:52:42 ↓ improving

Ref Indicator 2019/20 2020/21 Direction of Improvement Baseline End Yr1 travel Expectation RI1 % of staff responding positively to the NHS Staff 51.6% 53.0% ↑ improving improving year on Survey Q4b year and in top RI2 % of staff responding positively to the NHS Staff 28.9% 30.0% ↑ improving quartile for sector Survey Q4c by end year 5 RI3 % of staff responding positively to the NHS Staff 32.5% 33.0% ↑ improving Survey Q4d RI4 AQI System Indicator Stroke call to door (90th 02:20:00 02:21:00* ↑ deteriorating percentile) RI5 AQI System Indicator STEMI call to catheter 02:51:00 02:59:00* ↑ deteriorating insertion (90th percentile) *data only available to February 2021 (Stroke) and October 2020 (STEMI) at time of writing and therefore end year one will change

Objective Priorities To ensure our 1. Monitor and improve the clinical quality of our services through a robust audit programme

services are 2. Our care is evidence based and delivers the intended outcomes for patients and staff

e Effectiv effective 3. Utilise innovative methods to enhance care delivery and improve outcomes for patients

53

How will we achieve this? • Good clinical record keeping training and supporting clinical decision making • EMAS is a partner in research for simulation training using mobile technology • Gap analysis of training needs for reflective practice • Implementation of specialist paramedic role

• Staff have access to senior clinical leadership and clinical decision-making support • Continued implementation of the cardiac arrest strategy

Actions (year 1) Actions What will success look and feel like?

• Clinical record keeping training records • Evidence of EMAS involvement in relevant research projects • Gap analysis used to develop plan for reflective practice training • Specialist paramedics in post and positively evaluating impact • Clinical Coordination and Support Desk in Emergency Operations Centre • Cardiac arrest strategy objectives delivered • Patients feel they are getting a quality service and we are proud of the outcomes we are achieving for our patients

Evidence What progress has been made?

54 • Learning from Events (LfE) session focused session on record keeping plus mention of importance in almost all other LfE sessions throughout the year • EMAS research activity has continued to grow, including involvement in Covid related research studies • Reflective practice gap analysis put on hold during to pandemic response • First two cohorts of Specialist Paramedics in post and positive evaluation of impact presented to Quality and Governance Committee and Commissioner Meetings. Third cohort recruitment underway • Clinical Coordination and Support Desk running throughout pandemic with positive impact • Cardiac arrest team leader training rolled out despite pandemic response, cardiac arrest focused LfE delivered

• Positive patient feedback continues to outweigh complaints

EndYr1 • Develop and plan implementation of clinical record keeping training • Continued EMAS involvement in relevant research projects • Undertake gap analysis to develop plan for reflective practice training

• Continue with specialist paramedic recruitment and development, evaluate impact

• Continue to provide Clinical Coordination and Support Desk in Emergency Operations Centre • Continue to roll out cardiac arrest strategy objectives, evaluate impact

Yr2Actions

Ref Metric Standard 2019/20 Baseline 2020/21 Direction of End Yr1 travel

55 E1 % alternative pathway to ED 40.0% 33.49% 42.83%* ↑ improving E2 Average on scene time (conveyed) 00:30:00 00:38:25 00:41:35* ↑ deteriorating E3 Average on scene time (not conveyed) 01:00:00 01:06:39 01:11:05* ↑ deteriorating E4 Average post-handover 00:15:00 00:17:53 00:19:23* ↑ deteriorating E5 % Utstein Return of Spontaneous Circulation 50.0% 47.58% 43.10%** ↓ deteriorating E6 % Utstein Survival to Discharge 25.0% 21.5% 21.81%** ↑ improving Ref Indicator 2019/20 2020/21 Direction of Expectation Baseline End Yr1 travel EI1 % of staff responding positively to the NHS Staff 26.1% 28.0% ↑ improving improving year on Survey Q4i year and in top EI2 % of staff responding positively to the NHS Staff 83.5% 86.0% ↑ improving quartile for sector Survey Q7a by end year 5 EI3 % of staff responding positively to the NHS Staff 68.7% 72.0% ↑ improving Survey Q7c EI4 AQI Clinical Outcome Stoke Diagnostic Bundle % 98.1% 98.9%* ↑ improving compliance EI5 AQI Clinical Outcome STEMI Care Bundle % 71.8% 78.1%* ↑ improving compliance EI6 AQI Clinical Outcome Sepsis Care Bundle % 93.2% 90.2%* ↓ deteriorating compliance EI7 AQI Clinical Outcome Cardiac Arrest Care Bundle % 71.4% 88.2%* ↑ improving compliance *data as at 9 March 2021 ** data only available to February 2021 at time of writing and therefore end year one will change

Objective Priorities To ensure our 1. Embed a ‘quality culture’ of continuous learning, improvement and innovation

services are 2. Optimise the use of our available data to improve analysis, reporting, decision making and quality Led Well well led improvement

56 3. Our protocols, policies and procedures are evidence based and up to date How will we achieve this? • Revise quality reporting arrangements to provide greater levels of analysis, triangulation and assurance • Embed quality improvement at every level of the organisation, encourage ideas and involvement • Centralise comprehensive quality data sets to enable one version of the truth and facilitate triangulation

• Produce guidance for approving committees on obtaining assurance of the quality of our policies, procedures and assurance reports • Development of quality champions • Training needs analysis for quality improvement

Actions (year 1) Actions What will success look and feel like?

• Introduction of Quarterly Integrated Quality Report (IQR) • Quality Improvement activity reported in the IQR • Implementation of revised Quality Impact Assessment Policy • Comprehensive quality dashboards providing data at Trust, divisional and where appropriate station/ department level • Quality Champions active in the Trust • Training Needs Analysis used to develop training plan for Quality Improvement • Patients and staff have confidence that the leaders in the organisation put patients and staff first

Evidence What progress has been made?

57 • Integrated Quality Report (IQR) introduced and presented to Quality and Governance Committee (with the exception of Q3 due to competing pressures associated with Covid Q4 report includes full year data/ information) • Quality Improvement activity reported in the IQR • Revised Quality Impact Assessment Policy introduced with improved quality of assessments noted, Equality/ Quality Impact Assessment (EQIA) Panel terms of reference approved, the new panel will be established to consider transformation and cost improvement programme EIAs/QIAs to support identification of cumulative impact and interdependency between schemes • Divisional scorecards now implemented and used in Performance Management Reviews, commissioner version developed to provide local assurance • Quality Champions put on hold during pandemic response • Quality Improvement Training Needs Analysis put on hold during the pandemic response

• Positive patient feedback continues to outweigh complaints

EndYr1 • Continue to produce Quarterly Integrated Quality Report (IQR) • Continue to report Quality Improvement activity reported in the IQR • Implement and evaluate EQIA Panel • Continue to produce quality dashboards providing data at Trust and divisional level- use to provide assurance and

identify areas for improvement

• Implement Quality Champions across the Trust • Undertake Training Needs Analysis to develop training plan for Quality Improvement

Yr2Actions

58 Ref Metric Standard 2019/20 Baseline 2020/21 Direction of End Yr 1 travel W1 % appraisal rate (rolling twelve-month) 95%* 83.82% 51.55%** ↓ deteriorating W2 % compliance with statutory and mandatory training 95%* 85.80% 83.61%** ↓ deteriorating (online) 62.35%** (F2F) W3 % sickness absence 4.3% 6.22% 5.16%** ↓ improving W4 % attrition rate 10.0% 9.03% 8.89%** ↓ improving W5 % IR1 incidents closed within 7 days 95% 89.77% 86.84% ↓ deteriorating * as a result of the COVID-19 pandemic the deadline for achieving 2020/21 compliance was extended to end September 2021 ** data as at 9 March 2021

Ref Indicator 2019/20 2020/21 Direction of Improvement Baseline End Yr1 travel expectation WI1 % of staff responding positively to the NHS Staff 63.6% 69.0% ↑ improving improving year on Survey Q5b year and in top WI2 % of staff responding positively to the NHS Staff 21.9% 27.0% ↑ improving quartile for sector Survey Q11a by end year 5 WI3 % of staff responding positively to the NHS Staff 51.5% 61.0% ↑ improving Survey Q18c WI4 NHS Staff Survey % uptake 52.0% 50.0% ↓ deteriorating WI5 NHS Staff Survey engagement score 6.3 6.5 ↑ improving WI6 Freedom to Speak Up Index Score 71.9% 76.0% ↑ improving

a f e S Objective Priorities

59 To ensure our 1. Effective safety culture embedded across all areas with implementation of a systems approach to services are incident review and investigation to maximise learning, staff are treated fairly in a non-punitive way safe 2. Working in collaboration with partner organisations to maximise our efforts to learn from the things that go well, not just when things go wrong (in line with the NHS Patient Safety Strategy, 2019) 3. Our staff work in and our patients are cared for in a safe environment How will we achieve this? • Undertake a review to identify variation in incident reporting between divisions and teams • Revise our serious incident management procedure to align with the revised PSIRF

• Train our staff to undertake robust root cause analysis to better identify causes/contributory factors/ mitigating actions • Train staff in statement taking using ‘just culture’ methodology and to support do it once do it well to support multiple processes, eg coroners/ SI investigations/ police/ HR • Implement a learning log and introduce ‘learning from events’ sessions • Implement patient safety specialist role and develop plan to introduce patient safety partners in 2021/22 (as per NHS Patient Safety Strategy)

Actions (year 1) Actions What will success look and feel like?

• Less variation in reporting rates between divisions and teams, an increase in reporting overall with most low/ no harm • Revised serious incident procedure in place which aligns to new Patient Safety Incident Response Framework • Staff training records and improved quality of SI reports (feedback from commissioners/ coroners) • Staff training records and improved quality of statements (feedback from coroners/ HR) and staff feedback that process is less onerous, and they feel better supported • Learning log in place and regular schedule of learning from events – available on Totara • Patient Safety Specialist in post and clear plan in place to introduce Patient Safety Partners in 2021/22 • Patients are confident that if we make a mistake we will be open, honest and will learn, staff feel confident to raise concerns, know they will be supported, treated fairly if they do and that appropriate action will be taken in response

Evidence What progress has been made?

60 • Reporting overall has improved, less variation seen, and percentage of low/no harm incidents continues to consistently exceed the target of 90% • Revised serious incident procedure in place, including establishment of twice weekly Incident Review Group (IRG) and confidential IRG as required, expert panels to undertake Root Cause Analysis and agree actions/ recommendations and revised 72 hour and final report templates in use • SI Team external training had to be cancelled due to the pandemic response, but internal coaching has continued, and the Trust has received positive feedback from commissioners, Care Quality Commission and NHSEngland/Improvement regarding quality of reports • Staff training in relation to ‘account taking’ using just culture put on hold due to the pandemic response, but coaching has continued, and the Trust has received positive feedback from staff/ managers regarding the process and from Coroners regarding the quality of statements. A new process to minimize the need to obtain statements from road staff has been agreed with the Coroners whereby the Head of Quality for Coroners Services provides statements on the Trust’s behalf • Learning log recorded as part of IRG minutes. Regular schedule of Learning from Events delivered and available on Totara learning management system

• Patient Safety Specialist posts identified within the Trust (Deputy Director of Safety and Patient Experience and Senior Head of Quality). Plan for Patient Safety Partners delayed due to pandemic response • Duty of Candour and Being Open processes followed and positive feedback received from patients/ relatives who have

EndYr1 been involved in incidents. Family liaison officer role introduced • Continue to monitor incident reporting rates between divisions and teams, promote a reporting and learning culture • Implement revised Patient Safety Incident Response Framework when published • Continue to monitor quality of SI reports (feedback from commissioners/ coroners), provide feedback and coaching for

staff to maintain improvements

• Continue to monitor quality of statements (feedback from coroners/ HR) and staff feedback about process and support given • Continue to maintain a learning log via IRG and produce a regular schedule of learning from events – make available on Totara

Yr2Actions • Introduce Patient Safety Partners in 2021/22

61 Ref Metric Standard 2019/20 Baseline 2020/21 Direction of End Yr1 travel S1 IR1s per 1000 incidents n/a 5.75 6.75* ↑ improving S2 Patient Safety Incidents (PSIs) per 1000 incidents n/a 1.58 1.34* ↓ improving S3 % PSIs that are low or no harm 90% 94.48% 94.83%* ↑ improving S4 Serious Incidents per 1000 incidents n/a 0.06 0.04 ↓ improving S5 RIDDOR incidents n/a 93 65* ↓ improving S6 Safeguarding referrals per 1000 incidents n/a 0.03 0.05* ↑ improving S7 % Prolonged waits n/a 10.66% 5.99%* ↓ improving Ref Indicator 2019/20 2020/21 Direction of Expectation Baseline End Yr1 travel SI1 % of staff responding positively to the NHS Staff 42.6% 52.0% ↑ improving improving year on Survey Q16a year and in top SI2 % of staff responding positively to the NHS Staff 58.6% 66.0% ↑ improving quartile for sector Survey Q16c by end year 5 SI3 % of staff responding positively to the NHS Staff 50.5% 53.0% ↑ improving Survey Q16d SI4 % of staff responding positively to the NHS Staff 65.9% 70.0% ↑ improving Survey Q17b SI5 % of staff responding positively to the NHS Staff 52.3% 58.0% ↑ improving Survey Q17c *data as at 9 March 2021

Key

↑ improving Metric improved compared to previous year ↑ deteriorating Metric deteriorated compared to previous year where a higher metric threshold is better where a lower metric threshold is better ↓ improving Metric improved compared to previous year ↓ deteriorating Metric deteriorated compared to previous year where a lower metric threshold is better where a higher metric threshold is better

Appendix 2 – Workforce, education and development

62 Staff support and wellbeing

During 2020/21 EMAS has progressed initiatives to enhance staff support and wellbeing. Key achievements are included below:

Staff Support: • Peer to Peer – In February 2015 the Peer to Peer (P2P) and Pastoral Care Worker (PCW) support network was launched with 206 volunteer staff from across EMAS trained in supporting and signposting colleagues to further support where required. During 2020/21 the P2P/PCW support network has grown from strength to strength and now has 210 volunteers who have supported 4031 contacts through the year.

• Occupational Health – People Asset Management (PAM) group provides an Occupational Health service to EMAS, which includes, counselling, new starter medicals, vaccinations, management referrals and guidance, wellbeing and night worker assessments. In addition, an Employee Assistance Programme (EAP) is also available to staff on a 24 hour, 7 days a week basis and provides advice, guidance and support on the following issues:

1. Relationships 2. Working life 3. Incident and assault

63 4. Money matters 5. Family issues 6. Loss and change 7. Health concerns 8. Legal advice

• Sano MSK physiotherapy support – MSK physiotherapy support and/or workstation assessments provided for employees via a line management referral.

• MIND - In 2015 Mind, a national mental health charity, launched an ambitious and comprehensive four-year programme of activity aimed at reducing the stigma, promoting wellbeing and improving mental health support across the blue light services. EMAS became the first ambulance service in the country to sign the pledge in supporting this programme. EMAS also supported the programme by having Blue light champions, who are volunteers who help raise the awareness of mental health problems and challenge the stigma of mental health alongside their day-to-day roles.

Blue light champions are not counsellors but provide a listening ear and are able to signpost to relevant support and useful resources.

From 2019 this specific Blue light MIND programme came to an end. However, the work continues to be undertaken on a more regional basis rather than the initial nationwide concept. At EMAS there is work being undertaken in a more collaborative way with Lincolnshire Police and Lincolnshire Fire and Rescue services.

• Trauma Risk Management (TRiM) is a trauma-focused peer support system. The TRiM model builds resilience by basing itself on keeping employees functioning after traumatic events by providing support and education to those who require it.

TRiM practitioners are not counsellors, nor do they provide treatment. What they do is use already existing personnel management systems (ie occupational health) to assist normally distressed individuals to recover and, where necessary, ensure

64 that those who require it are referred for appropriate treatment at an early stage. There are currently 69 TRiM practitioners within EMAS and 45 TRiM recorded assessments were undertaken during the year 2020/21.

TRiM practitioners are required to undertake a course of refresher training every three years. A charitable funds bid was submitted to the Trust and approved. Refresher training for a total of 16 delegates was undertaken on the 11 March 2021 and on the 19 March 2021. The refresher training was provided by an external company called ‘March on Stress’.

The National Institute for Health and Care Excellence (NICE) are the UK's body which sanctions medical interventions. NICE have guidance on the management of post traumatic illnesses and suggests that for the first month after an incident, a policy of watchful waiting should be employed; that means keeping a watchful eye on individuals who have been exposed to the traumatic event. This does not just mean those who were 'there' but also those who might feel responsible such as those who might have been involved such has taking the initial call or those who have had to help with the aftermath. The EMAS TRiM scheme is a wholly ‘NICE-complaint’ model of peer group traumatic stress management.

• EMAS continues with its close association with The Ambulance Service Charity (TASC). TASC offers a range of one-to-one counselling and psychological well-being support with local counsellors to ensure ambulance staff do not have to travel far or stay away from home to receive this treatment. TASC also fund support for ambulance staff and their families struggling with stress-related illness or post-traumatic stress disorder (PTSD).

In certain cases, TASC are able to provide access to psychological well-being support via The Police Treatment Centre, for those with low level difficulties, taking a holistic approach and access to various wellbeing therapies.

• Induction – Staff continue to receive support information sessions on all induction courses for new staff joining EMAS to ensure awareness of the different support mechanisms that are available. The support information sessions are provided by the chaplain/staff support lead.

• Internal Support Network Groups – The LGBT+ (Lesbian, Gay, Bisexual, Transgender Plus) Support Network launched in March 2015 and continues to represent and support employees. The Black Asian Minority Ethnic (BAME) support group launched in March 2016. These support groups focus on issues poignant to individuals and provide a ‘group voice’ and support mechanism for staff within their community and providing valuable contribution to support learning and development of the working

65 environment.

• Mediation Service – EMAS provides an internal mediation service to employees who are experiencing conflict, frustration or disagreement with another employee or manager. The mediation service provides an informal approach to resolving issues in an aim to avoid escalation or formal processes being initiated.

• Spiritual and Pastoral Support – Reverend Kevin Charles, EMAS Chaplain, provides religious, spiritual and pastoral care for all staff. The provision of spiritual supports everyone in the fragile human life which we all share regardless of their religion, sexuality, belief, and culture. The spiritual and pastoral support consists of helping acts, directed towards the healing, sustaining, guiding, reconciling and nurturing of persons whose troubles and concerns arise in the context of daily interactions and ultimate means and concerns. What is offered:

1. a listening ear 2. prayer support 3. pastoral support at times of difficulty or crisis 4. help with bereavement 5. support in practicing a faith or spiritual tradition 6. religious and spiritual care with contacts available from other faith leaders should this be required.

Suicide Awareness - In 2018 the Association of Ambulance Chief Executives (AACE) published a paper in relation to suicide study recommendations. One of the recommendations was that all ambulance trusts should develop a mental health strategy with a specific emphasis on suicide. At EMAS we have established a Suicide Prevention Group that researches best practice to ensure that any national suicide prevention recommendations are incorporated within the strategy. EMAS has become a member organisation of Zero Suicide Alliance (ZSA). The alliance is ultimately concerned with improving support for people contemplating suicide by raising awareness of and promoting free suicide prevention training, which is accessible to all. The aims of the training are to enable people to identify when someone is presenting with suicidal thoughts/behavior, to be able to speak out in a supportive manner, and to empower them to signpost the individual to the correct services or support. EMAS’ actions have been to promote ZSA on the recent Suicide Awareness Day, encourage staff to undertake the free on-line training and have arranged for the training to be made available on the Totara system.

66 National NHS Staff Support Services

In response to the Coronavirus pandemic, NHS England and NHS Improvement promoted and gave access to all NHS staff to the following staff support services and applications. Regular articles promoting these services were also published in the EMAS weekly communication bulletin, Enews.

• The national ‘Every Mind Matters’ campaign provides some general tips and resources for maintaining mental wellbeing. • Mental Health First Aid England - https://mhfaengland.org/ provides resources such as the stress container, supporting your mental health while working from home, address your stress and empower half an hour. • Gov.uk website provides information regarding mental health and wellbeing support and dealing with the effect Coronavirus has on mental health. • Call the Samaritans emotional support line on 0300 131 7000 from 07.00 to 23.00 hours. • Contact Hospice UK bereavement and trauma support on 0300 303 4434 from 08.00 to 20.00 hours • Brave offered a free confidential counselling service over the phone for staff and close family members. A qualified therapist would call and provide a space to express feelings, fears and difficulties that are present as a result of the pandemic. Staff could text BRAVE to 60777 to book.

Psychological Self-Help Apps for NHS Staff

A range of psychological self-help applications including support for managing stress and anxiety, building resilience, being mindful, and aiding better sleep, were also made available for all NHS staff, at no cost until the following dates.

• Daylight - New users have until 31 March 2021 to sign up. All NHS accounts will remain active for 12 months from sign up (for example staff who signed up in February 2021 will have access until February 2022) • Headspace - 31 December 2021 • Sleepio - New users will have until 31 March 2021 to sign up. All NHS accounts will remain active for 12 months from sign up. • Unmind - 30 June 2021 • Liberate - 30 June 2021 • Movement for Modern Life 30 September 2021

67 Useful National helpline numbers and websites

• Samaritans 116 123 www.samaritans.org • Citizen Advice Bureau 03444 111 444 www.citizansadvice.org.uk • Mind 0300 123 3393 www.mind.org.uk • Carers UK www.carersuk.org • Alcoholics Anonymous 0800 9177650 www.alcoholics-anonymous.org.uk • National Gambling helpline 0808 8020 133 www.begambleaware.org • Victim support 08081689111 www.victimsupport.org.uk • Relate www.relate.org.uk

Financial Support

• TASC - financial wellbeing support services are available to any serving or retired ambulance staff member and their close family members. During financial difficulty even the simplest tasks, such as food shopping or paying a bill, can cause extraordinary worry and stress. Call on freephone 0800 1032 999 or visit https://www.theasc.org.uk/services-we- offer/financial-wellbeing/

• Citizens Advice - Citizens Advice offers free, confidential information and advice on your rights, including information about benefits, money and work. Citizens Advice can be contacted on: 03444 111 444 (Adviceline) or 03444 111 445 (Text relay)

Health and wellbeing • We have divisional Health, Wellbeing and Sickness Reduction local/divisional action plans. • We continued promotion of a zero-tolerance approach to physical violence/bullying and harassment and roll out of national guidance to tackle and eradicate bullying in the workplace. • Staff Safety and Management of Actual or Potential Aggression (MAPA) training is being rolled out to frontline staff and there was the introduction of the facility for CCTV on double crewed ambulances. • We are involved in the Association of Ambulance Service Chief Executive’s (AACE) Health and Wellbeing national group, with our Director of Human Resources and Organisational Development chairing for the national group.

68 • We continued our recognition schemes in relation to awards, including revision of the CEO Commendations and other recognition schemes. • A new Equality, Diversity and Inclusion Strategy 2020-2023 was formally approved in August 2020 and the priorities and objectives are being progressed. • We have continued to promote the use of the Disability Personalised Record /Tailored Adjustment Plan for staff to support them in the workplace. The reasonable adjustments guide, supports the EMAS’ commitment to pro-actively advancing equalities by encouraging an inclusive and supportive workplace, where colleagues with a disability or health condition are able to be open about their disabilities or condition and are valued as an individual for their skills and contribution to the organisation. • The Suicide Prevention Group took forward national work to increase awareness and improve education. • We relaunched the Stress Audit Toolkit, including a Wellness action plan. • We have developed a new Sickness Absence Reduction Programme to reduce sickness by 1% through a number of initiatives, including review of rotas, introduction of station manager posts to provide greater management focus and implementation of fast track employee relations processes to reduce personal impact. • Workforce Planning and ongoing recruitment to continue to increase the establishment. • We are continuing to focus on health and wellbeing topics on a monthly basis in our internal weekly staff communication Enews, in line with the NHS calendar of events. Topics covered have included; mental health, anxiety, stress and depression and PTSD, back care/musculoskeletal, keeping fit and healthy, stop smoking support, men’s and women’s health and winter wellbeing. • Mental Health First Aid/ Mental Health awareness – EMAS have two trained Mental Health First Aid staff who are continuing to raise mental health awareness and provide support to staff; developing a Mental Health Action Plan relating to the thriving at work mental health standards and will deliver Mental Health First Aid training to frontline managers. • Continued review of services from Occupational Health and tender activity for provider - EMAS is continuing to work in collaboration with our contracted occupational health provider to ensure the provision of a high quality, prevention focused, and comprehensive occupational health service. This includes reviews with PAM and the HR team assessing each individual case. Through a six-weekly contract review meeting with Occupational Health and key members of EMAS, key performance indicators and trends are monitored, and actions agreed. • Seasonal influenza vaccination programme 2020/21 – this year EMAS vaccinated 87% of staff against the seasonal flu virus. This was a 6% increase in staff vaccinated compared to the 2019/20 programme. • In response to the COVID-19 pandemic and national guidance, individual risk assessments have been undertaken for all EMAS staff and a COVID vaccination programme has commenced.

69

Staff engagement

• Continued engagement with staff via the Facebook live sessions, which are attended by Executive Board Members and Non- executive directors and senior managers. • Communications and Engagement Strategy aligned with local communications and engagement plans. • Local divisional action plans being developed to support engagement and key challenges from the 2020 staff opinion survey.

NHS Staff Survey 2020

The NHS Staff Survey provides an opportunity for Trusts to survey their staff in a consistent and systematic way. This makes it possible to build up a picture of staff experience and to compare and monitor change over time, and to identify variations between different staff groups.

The results are primarily intended for use by NHS organisations to help them review and improve staff experience. The Care Quality Commission (CQC) will use the results from the survey to monitor compliance with essential standards of quality and safety.

New questions were added for 2020 ‘The COVID-19 Pandemic’ Q20a-Q20d (your experience during the Covid-19 pandemic – working in Covid-19 specific wards/areas, redeployment, remote/home working, shielding). Q21a and Q21b – two free text questions (lessons that should be learned and what worked well during COVID-19).

The annual Staff Survey was conducted by the Picker Institute Europe on behalf of East Midlands Ambulance Service NHS Trust. Picker administered the survey for 8 ambulance trusts (including EMAS) in 2020, which provides the Trust with benchmarking data against this sample of ambulance trusts.

The NHS England benchmarking report is based on the full sample of our staff and provides a comparison of our Trust responses against those across the NHS, and these results are used for national reporting purposes. The complete NHS Benchmarking report can be found at Appendix 1.

The Staff Survey was launched in the Trust on the 5 October 2020 and closed on 27 November 2020.

70 Response Rates

A total of 3,942 staff were sent a questionnaire of which 3,926 were eligible to complete the survey (eligibility does not include any staff member who is on long term sickness absence over 90 days or any staff leavers after the 1 September 2020). 1,957 staff returned a completed survey questionnaire, giving a response rate of 50%. Whilst this represents an overall positive response to the survey, it is a lower response rate by 2% when compared to the previous year’s survey response rate of 52%.

The average response rate for the ambulance sector in 2020 was 58%.

A comprehensive communication plan supported the 2020 survey, this commenced with communications from the Chief Executive requesting staff to complete their survey and highlighted the importance of the results which contribute to improved care for patients and working conditions for staff. This message was reiterated in the covering letter accompanying the Staff Survey. This was supported by local ownership through divisional Ambulance Operations Managers, Divisional Senior Leadership Team Meetings and monitoring through Divisional Performance Management Reviews.

Other mechanisms that supported and promoted the completion of the Staff Survey, included:

• Access to the survey online or on paper (and via telephone). • Direct requests to heads of departments and divisional general management teams. • Dedicated time was provided to staff to complete their survey. • Patient Transport Services (PTS) requested all their surveys questionnaires to be available online, and for Derbyshire PTS this resulted in a response rate of 58.3% which is a 17.8% increase compared to the previous year. • All paper survey questionnaires had a covering letter informing the recipient that the questionnaire could be completed online using a specific code quoted. • Regular information and promotion via Enews and the intranet, Insite. • Trade union colleagues supported the promotional campaigns.

Assurances to staff regarding confidentiality were provided regularly via social media; Chief Executive messages in Enews; a video was available from Picker; and Trade Union reinforcement.

Comparisons to the 2019 Staff Survey

71 A total of 78 questions were used in the 2020 survey, compared to the 2019 survey the Trust is: Significantly better on 40 questions Significantly worse on 0 questions No significant difference on 35 questions

72 Headlines from the Survey Findings (from the Picker Results)

The Trust improved significantly on the following questions from the last survey: % Most improved from last survey 2017 2018 2019 2020 increase Q11d. In last 3 months, have not come to work when not feeling well enough to 30% 31% 31% 44% 13% perform duties Q4g. Enough staff at organisation to do my 24% 23% 26% 37% 11% job properly Q16a. Organisation treats staff involved in 38% 35% 42% 52% 10% errors fairly/near misses/incidents fairly Q18c. Would recommend organisation as 41% 49% 52% 61% 9% place to work Q4f. Have adequate materials, supplies and 50% 51% 55% 63% 8% equipment to do my work

% Least improved from last survey 2017 2018 2019 2020 decrease Q11f. Not felt pressure from colleagues to come to work when not feeling well 86% 86% 85% 82% -3% enough Q11b. In last 12 months, have not experienced musculoskeletal (MSK) 68% 63% 66% 65% -1% problems as a result of work activities Q12d. Last experience of physical violence 71% 74% 72% 71% -1% reported Q5c. Satisfied with support from colleagues 80% 82% 83% 82% -1% Q13c. Not experienced harassment, 82% 83% 83% 83% 0% bullying or abuse from other colleagues Top 5 scores compared to the average response (compared to other Ambulance Services):

Average Response EMAS Response Top 5 scores (compared to average response) rate rate 73 Q6b. I have a choice in deciding how to do 41% 48% my work Q2c. Time often/always passes quickly when I 58% 63% am working Q5f. Satisfied with extent organisation values 36% 40% my work Q13d. Last experience of 45% 50% harassment/bullying/abuse reported Q14. Organisation acts fairly: career 75% 80% progression

Bottom 5 scores compared to the average response (compared to other Ambulance Services):

Bottom 5 scores (compared to average Average Response EMAS Response response) rate rate Q11d. In last 3 months, have not come to work when not feeling well enough to 48% 44% perform duties Q4i. Team members often meet to discuss 29% 28% the team's effectiveness Q16a. Organisation treats staff involved in 53% 52% errors/near misses/incidents fairly Q5h. Satisfied with opportunities for flexible 40% 39% working patterns Q12d. Last experience of physical violence 72% 71% reported

74 2020 NHS Staff Survey Results – Theme Results – Overview

The theme results above would suggest that the Trust is in-line or above the average results when compared to peer organisations. The Trust is reported as achieving the best result score for ‘Health and Wellbeing’.

75 COVID-19 specific free text questions for 2020

As part of the national NHS staff opinion survey for 2020, it was determined nationally to introduce two specific questions related to COVID-19 and the experiences of NHS staff during the pandemic.

The questions posed were: Q21a - Thinking about your experience of working through the COVID-19 pandemic, what lessons should be learned from this time and Q21b - What worked well during COVID-19 and should be continued.

The key themes for these questions based on EMAS staff responses are detailed below.

Q21a - Thinking about your experience of working through the COVID-19 pandemic, what lessons should be learned from this time?

There were many positive responses (997 total number of responses) contained within the report which related to themes: • Reduction of bureaucracy • Being flexible and making things happen • Clarity in guidance • Working from home • Teamwork • Personal Protective Equipment (PPE) • Communications • IT – Microsoft Teams availability • Greater use of alternative pathways

Q21b - What worked well during COVID-19 and should be continued? The EMAS staff responses (972 total number of responses) suggest that the following areas did work well during the pandemic and should be continued going forward. • Communications • Remote working / flexible working • IT / Microsoft Teams • Alternative pathways / triaging / Card 36 • PPE • Reduction of bureaucracy • Staff support • Team work 76

Workforce Race Equality Standard (WRES) Outcomes

The percentage of staff experiencing harassment, bullying or abuse from patients, relatives or the public in the last 12 months outcome is shown in the above line graph. The above graph shows there has been an increase in BAME staff experiencing harassment, bullying or abuse from patients showing a 4.3% increase from the previous year. There has been a 3.4% decrease from the previous year for white staff experiencing harassment, bullying or abuse from patients. Comparing the Trust’s results to the average response rates of other Trusts, the responses shown are below the average response rate.

77 The Trust as part of its Workforce Race Equality Standard report for 2019/20 identified that a key action to address the increase in BAME staff receiving experiencing harassment, bullying or abuse from patients, relatives or the public to raise their awareness of hate crime and implement reporting, recording and monitoring procedures.

The Trust is also to embark on a pilot scheme on the wearing of body cameras for frontline staff within the Nottinghamshire and Derbyshire A&E divisions from April 2021. This should reduce the number of incidents of this nature occurring and provide additional assurance to our frontline staff. In the event an incident does occur then the evidence obtained from the body worn camera will assist in the prosecution of the offenders.

78 The percentage of staff experiencing harassment, bullying or abuse from staff in the last 12 months outcome is shown in the above line graph. The above graph shows there has been a slight increase in BAME staff experiencing harassment, bullying or abuse from staff showing a 1.9% increase from the previous year. There has been a 1.5% decrease from the previous year for white staff experiencing harassment, bullying or abuse from staff. Comparing the Trust’s results to the average response rates of other Trusts, the responses show the EMAS response rate for white staff is slightly higher than the average response by 1.5% and the response rate for BAME staff is 0.8% higher at the Trust than the average response rate.

The Trust’s FTSU Guardian continues to work pro-actively with the Chair of the Trust’s BAME network to raise awareness of FTSU and encouraging colleagues from BAME backgrounds to speak up and raise concerns to ensure that matters of this nature are duly addressed. The Trust has appropriate policies and procedures in place to address dignity and respect in the workplace, and these Employee Relations matters and trends are monitored through the Workforce Committee.

The Equality, Diversity and Inclusion team have produced a comprehensive equality, diversity and inclusion training plan which will commence on 1 April 2021 to educate and generate great awareness across the Trust, and the training programme includes a range of programmes to address workforce issues relating to bullying, harassment, civility and respect within the workplace. In addition, a series of Equality Briefing papers have been produced on equality issues such as racism in the workplace, micro aggressions and bystander syndrome to further support education and development of staff. The briefings are being cascaded throughout the Trust and are also accessible on the Totara learning management system.

79

80 The percentage of staff believing that the organisation provides equal opportunities for career progression or promotion is shown in the above line graph. The above graph shows there has been a significant increase in BAME staff believing that the organisation provides equal opportunities for career progression or promotion showing a 13.4% increase from the previous year. There has been a 0.7% increase from the previous year for equal opportunities for white staff. Comparing the Trust’s results to the average response rates of other Trusts, the responses show the EMAS response rate for white staff is higher than the average response by 2.9% and the response rate for BAME staff is 0.6% higher at the Trust than the average response rate.

The Trust scored higher in comparison to other ambulance trusts in response to Q14. Organisation acts fairly: career progression. The Trust scored an 80% response rate in comparison to the average score of 75%.

81

The percentage of staff who have received discrimination at work from manager/team leader or other colleagues in last 12 months is shown in the above line graph. The above graph shows there has been an increase in BAME staff receiving discrimination at work 82 showing a 1.2% increase from the previous year. There has been a 1.2% decrease from the previous year for discrimination at work for white staff. Comparing the Trust’s results to the average response rates of other Trusts, the responses show the EMAS response rate for white staff is lower than the average response by 1.1% and the response rate for BAME staff is 1.2% lower at the Trust than the average response rate.

A specific action to be taken will be to liaise with the divisional management teams in addressing this issue and identifying why there has been an increase in the response rate.

Action Plan for 2021/22 in response to the 2020 survey findings

The 2020 Staff Opinion Survey provides information on staff members overall experience within EMAS. It is evident from the responses that there are many positives. It is also evident from the 2020 staff opinion survey that there are further areas for improvement. Initial identified areas for continued improvement include:

• Increase the opportunities for flexibility/flexible working particularly in frontline roles. • Increase civility and respect between colleagues • Identify rationale for increased MSK and identify additional support/interventions to address this • Increase opportunity for team meetings • Increase reporting of physical violence • Continued development of just and learning culture ensuring staff involved in errors / near misses / incidents are treated fairly

A corporate Staff Survey action plan, which will incorporate divisional actions plans will be presented to the Trust Board in May 2021.

83 Appendix 3 – Data Security and Protection Toolkit (previously known as IG Toolkit)

The EMAS Head of Information Governance and Data Protection Officer is responsible for collating, checking and uploading evidence to support the Data Security and Protection Toolkit (DSPT) for our service. Assurance on the process to collect the evidence is overseen by the EMAS Information Governance Group, chaired by the Head of Information Governance & Data Protection Officer, which reports into the Information Assurance Group, chaired by the Senior Information Risk Owner (SIRO), which in turn is accountable to the Finance and Performance Group.

One incident was assessed as identifiable during the initial investigation stage (within 72 hours of identification). However, following further fact finding this was downgraded and did not require external investigation.

EMAS is currently at ‘standards not met’ as we have currently provided evidence items for 58 of the 111 mandatory evidence items at the end of March 2021. The DSPT was not released until 30 November 2020 with an extended deadline for compliance of 30 June 2021 due to the COVID-19 national crisis. It is anticipated that the Trust will be able to meet all but one of the remaining evidence items. The outstanding item will be completed in September 2021 and is reliant on a new telephony system being implemented. This system has been delayed due to the pressures on the service due to COVID. However, mitigations are in place that reduce any risk relating to this delay.

General Data Protection Regulation (GDPR)

EMAS’ compliance to the GDPR and Data Protection Act 2018 is monitored by the Information Governance Group, Information Assurance Group and the Finance and Performance Committee.

The Head of Information Governance also acts as the Data Protection Officer, managing virtual workstreams including communications, to support the fair processing notices and procurement, to support the contract reviews. Information relating to GDPR is communicated to all EMAS colleagues through the staff digital magazine Enews, and through statutory and mandatory education.

84 Appendix 4 – What we have done to improve clinical effectiveness - Research and Development

EMAS research status Research active organisations have been shown to provide better quality and outcomes of care.1 2 The reasons for this include the positive attributes and attitudes of those staff involved in research, the benefits of multidisciplinary collaboration, additional training and education provided, and specialisation of staff. Knowledge exchange between practitioners and researchers also ensures that the research is more relevant to practitioners and also more likely to be implemented; according to Boaz and colleagues (2015), “organisations in which the research function is fully integrated into the organisational structure can out- perform other organisations that pay less heed to research and its outputs”.3

The CQC considers research activity in trusts as an indicator of high quality, because of the associated improvements in patient care, outcomes and staff training and development.4

NHS England in its National Research Plan identifies that: “Research is vital in providing the evidence we need to transform services and improve outcomes, eg in developing new care models, redesigning urgent and emergency care…”. It notes that: “By fully integrating research into our organisation we can outperform organisations that do not, leading to better quality care and improved use of resources.” Research and innovation are an essential part of ‘Next steps on the NHS five-year forward view’. Research is not just an added extra or option, it is seen by NHS leaders, policymakers, staff and patients as essential.

EMAS take a proactive approach to research with the aim of identifying gaps in care, further improving care and safety, educating and training staff, reducing waste by stopping ineffective treatments, informing guidelines and policies and enhancing our organisational reputation. EMAS have recruited 482 participants to four portfolio projects this year (Promoting staff wellbeing in UK NHS Ambulance personnel SWAP, Ambulance ‘Hypos can Strike Twice’ (Ambu-HS2) study, CARA: A cross-sectional survey evaluating the effects of the COVID-19 pandemic on the wellbeing of ambulance personnel in the United Kingdom and Community First Responders’ role in the current and future rural health and care workforce) which will impact CRN funding for next year.

1. Current research

85 1.1 COVID-19 Research

During the COVID-19 pandemic the Health Research Authority (HRA) introduced fast track study reviews and amendments to existing studies for COVID-19 related studies to speed the development of tests and treatments for, and to build an evidence base around, COVID-19.

EMAS are participating in four COVID-19 related studies.

1.1.1 Exploring determinants of access to staff wellbeing and networks support (SWANS) among COVID-19 Elevated Risk Members of Staff (ERMS) working in Lincolnshire National Healthcare Service (NHS) Trusts during the COVID-19 pandemic (Lincolnshire SWANS study) Lincolnshire Community Health Services NHS Trust; Portfolio

Aims to explore barriers and facilitating factors to accessing staff wellbeing networks and support especially in response to the COVID-19 pandemic and how elevated risk members of staff compare in terms of challenges and opportunities.

Progress: Organisational approval issued and open for recruitment Feb 21

Recruitment: Up to 40 across all sites Monitoring: Not due

1.1.2 The COVID-19 Ambulance Response Assessment Study (CARA) South East Coast Ambulance NHS Foundation Trust; Portfolio

86 Aims to understand the evolving and cumulative effects of working during the COVID-19 outbreak on the psychological health of those clinicians and other patient facing staff working in ambulance services (and other settings employing paramedics) during the COVID19 pandemic.

Progress: Write up in progress, expected date of final report not confirmed, monitoring to continue

Recruitment: 167 Monitoring: Completed

Links to Trust Vision: Develop, collaborate – Information gained from the study may inform staff support and wellbeing mechanisms during times of increased pressure and demand across ambulance trusts

1.1.3 Ambulance calls for Substance use and Alcohol in a Pandemic (ASAP) University of Lincoln

The project aims to explore ambulance service attendance at incidents involving alcohol and/or substance use over the period of the pandemic lockdown, and the following months, to determine prevalence and explore factors such as patient gender, age, ethnicity or location and to explore the clinical decision making of ambulance crews such as conveyance to hospital in relation to crew members' gender, age, qualification level or seniority

Progress: Analysis of initial data in progress, next data to be sent after March 2021

Recruitment: Not applicable Monitoring: Not due

Links to Trust Vision: Respond, Develop: Exploring the effect of pandemic call demand to alcohol and substance use related calls to aid future planning and understanding of "at risk" groups 1.1.4 What TRIage model is safest and most effective for the Management of 999 callers with suspected COVID-19? A linked outcome study (TRIM) Swansea University – NIHR UKRI bid, portfolio

87 Evaluation of triage models use to manage emergency ambulance service care for patients with COVID-19 who call 999 in England, Wales, and Scotland. Comparing processes and outcomes, identifying adverse incidents, and missed or under triaged cases and to explore the experiences and concerns of clinical and managerial staff about implementation of triage protocols.

Progress: Approvals in place

Recruitment: 24 for whole study, EMAS tbc Monitoring: Not due

Some current studies, such as SWAP, listed below have included additional COVID-19 elements, to capture the current pandemic situation.

Further Studies which are detailed in the application section 3, have also utilised COVID-19 funding streams, such as a collaboration study with seven ambulance services and Kingston University, based around care homes and further collaborative work within Lincolnshire looking at anxiety in workforce within NHS trusts in Lincolnshire with the University of Lincoln.

1.2 Full research projects (non COVID)

We are currently participating in six additional full research projects which are detailed below and are awaiting the final report for one full research projects; this is shown in section 2.5.

1.2.1 Epidemiology and Outcome from Out of Hospital Cardiac Arrest (OCHAO) Warwick University 88

This project aims to collect and summarise high-quality data to support UK initiatives to improve outcomes from out of hospital cardiac arrest.

Progress: Monthly data upload to the registry. Supports reporting of cardiac arrest treatment and outcomes within EMAS. Output from the registry allows results to be benchmarked against national data and highlights areas which may influence improvement in outcome. Site agreements which had become out of date were renewed in February 2020.

Recruitment: N/A Monitoring: Not due

Links to Trust Vision: Respond, Develop, Collaborate – using data to drive improvement in care and outcome for cardiac arrest patients through collaborating with University of Warwick and national ambulance trusts.

1.2.2 Effect of implementing an ambulance clinician delivered hypoglycaemia leaflet (‘Hypos can strike twice’) on repeat ambulance calls, attendances and transports to hospital: non-randomised stepped wedge and process evaluation University of Lincoln/EMAS – Portfolio study

Evaluation of the impact of a clinician delivered hypoglycaemia leaflet on repeat ambulance calls, staff and patients and potential to scale up the intervention.

Progress: Staff and patient surveys and interviews in progress. Amendment to extend project to end of March was approved. Oral presentation will be given at EMS999 conference 2021 Recruitment: 188 Monitoring: Completed Links to Trust Vision: Develop, Collaborate – collaboration with University of Lincoln to aid the development of more rapid community response teams to prevent unnecessary hospital admission and speed up discharge to home improving the health care and independence of those living with diabetes.

1.2.3 Promoting Staff Wellbeing (SWAP) Yorkshire Ambulance Service - Health Education England Funded Portfolio Study

89 Identification of characteristics of successful employee mental wellbeing services in UK ambulance services and develop understanding how existing services can be improved.

Progress: Due to COVID19 an amendment to the project replaced focus groups with telephone interviews. Recruitment to interviews and staff survey closed 23 September 2020. Analysis and write up is in progress.

Recruitment: 120 Monitoring: in progress

Links to Trust Vision: Develop, Collaborate – collaborating with other Trusts to inform development of services aimed at improving the wellbeing of ambulance staff.

1.2.4 Community first responders’ role in the current and future rural health and care workforce – NIHR Bid University of Lincoln, portfolio

Study of contribution of Community First Responders to rural healthcare, value for money, how they are perceived by patients and other providers, and how CFR schemes can be developed to support future rural health and care services.

Progress: Analysis of data for work packages 1 and 2 in progress Recruitment for patient interviews for work package 3 is in progress 90 Write up of paper on documentary analysis in progress

Recruitment: 7 Monitoring: Not due

Links to Trust Vision: Respond, Develop, Collaborate – Collaborating with community voluntary organisations to develop services aimed at improving delivery of appropriate, timely care for patients.

1.2.5 IMproving the Ambulance recognition and Response for patients who are at Imminent risk of cardiac arrest: The IMARI Study South Western Ambulance Service, University of the West of England

Aims to improve the recognition of and response to patients contacting the 999-ambulance service who are critically ill, and at high risk of suffering a cardiac arrest before they reach hospital.

Progress: All permissions in place, awaiting confirmation to start, current project status “in set up”. EMAS involvement will be in work package 3

Recruitment: Expected 12 Monitoring: Not due

Links to Trust Vision: Respond, Develop, Collaborate – improving recognition of patients at imminent risk of cardiac arrest on contact with 999 ambulance service to develop improved response to those patients; collaboration with other ambulance Trust to discuss and test findings from data analysis and generate ideas to develop and test interventions.

1.2.6 Emergency Medical Service Call Condition Cluster Study (EMSC3) University of Lincoln, McMaster University (Ontario, Canada)

Identification of the epidemiology of spatial clustering of single and multiple acute condition related ambulance calls in the East Midlands and Ontario considering factors including socioeconomic deprivation, rurality, and social housing. The 91 primary outcome will be the identification of spatial clusters and transportation rates in children (<18) and adults (18+) for acute (initially respiratory) presentations in people with underlying or multiple at-risk factors including for suspected SARS- COV2 infection (e.g. chronic heart, lung disease or diabetes). Secondary outcomes include a comparative analysis of health care systems in the UK (East Midlands) and Canada (Ontario)

Progress: Analysis of first tranche of data in progress including comparisons with Canadian data. Initial papers being written for publication. Final tranche of data supplied to UoL. Regular meetings with UK and Canadian members held on progress with project and to discuss other potential joint projects

Recruitment: NA Monitoring: Not due

Links to Trust Vision: Develop, Collaborate – identification of spatial clusters of commonly occurring ambulatory conditions and exploration of underlying mechanisms and factors that influence them to inform development of future ambulance response; collaboration with partner organisations in Canada to compare similarities and differences in clustering and mechanisms.

2. Academic projects

EMAS CARU aims to support EMAS and external students in their academic research to help widen the pool of active researchers within the health and social care sector and to support the widening of the pre-hospital emergency care evidence base.

We currently have six academic projects in progress, including one related to COVID-19, within the Trust and these are listed below by theme. There is one study which is complete but awaiting receipt of the final report; this is shown in Section 2.5.

COVID-19

92 2.1.1 The Psychosocial, Relational and Emotional Consequences of Occupational Trauma Exposure During and Following A Pandemic: Insights from NHS Emergency Ambulance Personnel in England University of York

Exploration of the occupational psychosocial, emotional and relational experiences of NHS emergency ambulance personnel working during and following a pandemic outbreak and psychosocial, emotional and relational impacts of responding to the pandemic as a frontline emergency NHS ambulance responder.

Progress: Transcription and analysis in progress

Recruitment: 3 Monitoring: Not due

Links to Trust Vision: Develop: Exploration of occupational psychosocial, emotional and relational experiences of and impacts on NHS emergency ambulance personnel during and following a pandemic outbreak to highlight recommendations for promoting and supporting psychosocial and emotional wellbeing in ambulance personnel during and after large-scale incidents such as pandemics.

Personal development/staff welfare

2.1.2 Transition experiences of Polish Paramedics Kacper Sumera, Edge Hill University – PhD study

Investigation of the experiences, challenges and barriers and training needs of overseas paramedics transitioning to UK ambulance services.

Progress: Stage one complete, study suspended for 6 months due to COVID-19 pandemic; Stage to survey to be developed and delivered in 2021.

Recruitment: Not yet completed Monitoring: Not due 93

Links to Trust Vision: Develop – expansion of knowledge base around integration of overseas staff.

Patient Safety

2.1.3 Investigating clinical safety, appropriate and acceptability of telephone advice for low urgency calls Joanne Coster, University of Sheffield – PhD study

Investigating the clinical safety, appropriateness, and acceptability to patients of Hear and Treat pathways.

Progress: First stage of the project completed. Second stage analysis of data and write up in progress. Expected completion April 2021

Recruitment: not known Monitoring: In progress

Links to Trust Vision: Respond, Develop, Collaborate - collaboration with University of Sheffield project with potential to improve hear and treat response systems to reduce patient demand on ambulance services.

2.1.4 Near Misses in healthcare and non-healthcare organisations Nicholas Woodier, Nottingham University – PhD study

Development of an evidence-based framework for the reporting and analysis of near-miss incidents in healthcare drawing on evidence from healthcare and high-safety industries.

Progress: Report writing in progress. Monitoring: Not due

Links to Trust Vision: Develop – contributing to work aimed at increasing patient safety.

94

Community studies

2.1.5 Delivering ambulance service care that meets the needs of Eastern European migrants who have used the ambulance service in Lincolnshire Viet-Hai Phung, University of Lincoln – PhD

Investigating how care can be improved to meet the needs of Eastern European migrant users of the ambulance service in Lincolnshire.

Progress: WP1 – Systematic review completed and pending publication in BMC Health Services Research. WP2 – 15 interviews completed and analysed, 1st draft of paper submitted to Qualitative Health Research. WP3 – in progress. Data collection nearing completion. Completion of full study and thesis anticipated to be October 2021.

Recruitment: 15 Monitoring: Not due.

Links to Trust Vision: Develop and Collaborate – potential to inform improvements in care and wider healthcare of the Eastern European community within Lincolnshire.

Response to Cardiac Arrest

2.1.6 What are the primary factors influencing the on-scene use of mechanical resuscitation devices in non-traumatic cardiac arrests with East Midlands Ambulance Service?

Robert Spaight, EMAS/Keele University – MBA

To determine which factors predict use of a mechanical resuscitation device within EMAS to inform future strategy.

95 Progress: Analysis of data and write-up in progress.

Recruitment: N/A Monitoring: In progress

Links to Trust Vision: Respond, Develop – Potential to improve knowledge around the appropriate point to implement mechanical resuscitation and to inform cardiac arrest strategy.

2.2 Evaluation projects

Evaluation of projects, pathways, drugs, and devices before or after implementation is vital in assessing whether they work, are cost effective and safe. Part of CARU’s role is to support evaluation projects within the Trust. CARU are currently supporting one evaluation project.

2.2.1 Machine learning to evaluate Ambulance calls to Care Homes (MACH) –observational study University of Lincoln/CARU

Evaluation of demographic and clinical predictors of ambulance attendance and conveyance to hospital for people residing in care homes.

Progress: Data analysis ongoing, delay due to COVID-19 pandemic and change in research team, completion expected May 2021.

Recruitment: N/A Monitoring: Not due

Links to Trust Vision: Respond, Develop, Collaborate – Collaboration with the University to develop an understanding of predictors for attendance and conveyance of this group of patients which may help in developing services which better meet their healthcare needs and reduce demand on services.

96

2.3 Completed studies awaiting final reports

Research projects

2.3.1 Not Alert International Academies of Emergency Dispatch (IAED)

An assessment of the safety and efficacy level of Alertness Diagnostic tool within the existing MPDS/ProQA system to aid refinement of the tool.

Links to Trust Vision: Respond, Collaborate – Collaboration with provider of EMAS despatch system to improve the safety of coding used to determine the appropriate response to patients.

Academic projects

2.3.2 Learning from Serious Incidents within NHS Ambulance Services Heidi Scott-Smith, University of Derby – PhD study

Review of root cause analysis processes within NHS settings to prove or disprove that if the correct root cause is not identified appropriate actions are not implemented.

Links to Trust Vision: Develop – potential to inform policies aimed at improving patient and staff safety.

97 3. Projects at development or application stage

CARU have been working closely with academic and ambulance service collaborators to develop and set up new research studies or have expressed interest in participating in projects.

3.1 Co-applicant projects

EMAS are co-applicants on four bids. One project which had been unsuccessful in its first bid has subsequently been successful on a second bid. A decision is awaited on the other two which, if successful, will mean the projects are accepted onto the portfolio; one of these has recently been put forward to round two of the bid process. The third project had been unsuccessful on the first bid and options for further bids are being explored.

3.1.1 COVID-19: Clusters, causes, triage and vulnerability (COVID: CCTV) University of Lincoln; DHSC/UKRI COVID-19 Rapid Response initiative

This study aims to contribute to the national response to controlling the COVID-19 pandemic by identifying unusually high clusters of suspected COVID cases, enabling a rapid and successful response in near real-time.

Progress: Bid submitted, awaiting outcome

3.1.2 Exploring the use of pre-hospital pre-alerts and their impact on patients, ambulance service and Emergency Department staff University of Sheffield; NIHR HS&DR, Portfolio

This study aims to understand how pre-alert decisions are implemented by ambulance clinicians, and the impact of these on receiving EDs, to identify principles of good practice, areas of uncertainty and areas for improvement.

Progress: A second bid to NIHR has been successful and approval processes are in progress.

98 3.1.3 Supporting the ambulance service to safely convey fewer patients to hospital by developing risk prediction models and a decision support tool: Risk of ADverse Outcomes after a Suspected Seizure (RADOSS) University of Liverpool; NIHR HS&DR bid Portfolio

Development of a decision support tool to help paramedics understand the risks and benefits of transferring a patient suffering a seizure to A&E.

Progress: Bid submitted and shortlisted for stage 2

3.1.4 Learning from the impact of COVID-19 on Care Home and emergency ambulance service usage and experience to enhance the ongoing relationship and outcomes for residents: a mixed methods investigation Kingston University, The Health Foundation COVID-19 Research Programme bid Portfolio

Exploration of the usage and experiences of emergency ambulance services responding to calls to residents of care homes during the first year of the COVID-19 pandemic to ascertain how emergency ambulance services policies, patterns of usage of and responses to care home residents changed during the pandemic, the impact the COVID-19 pandemic had on processes and outcomes for care home residents and what insights can be gained into the clinical presentations of the care home resident that are being escalated into emergency ambulance calls.

Progress: Health Foundation bid unsuccessful exploring other funding calls

3.2 Collaboration

The following projects are ones on which EMAS are collaborating. EMAS are not participating in the randomised trial of clinical and cost effectiveness of administration of prehospital fascia Iliaca compartment block for emergency hip fracture care Delivery (RAPID2) study due to concerns around aspects of the project. 99

3.2.1 Pre-hospital use of hemostatic Celox® in emergency medical services Medtrade Products Limited; Portfolio

To collect clinical follow up data on the performance and safety of the device, as CE Marking was based on equivalence.

Progress: In initial talks, awaiting final protocol – no further updates

3.2.2 Do chest compressions generate detectable aerosols during cardiopulmonary resuscitation in patients with COVID-19? University of Leicester, NIHR COVID-19 bid, Portfolio

To investigate whether chest compressions generate detectable aerosols during cardiopulmonary resuscitation in the context of SARS-Cov-2 using a cadaver model and through research of adult cardiac arrests in hospital and the community and whether viral aerosols are produced during chest compressions that could infect those providing CPR

Progress: Bid submitted to stage 1, awaiting result

3.2.3 Design and delivery of staff training in managing dementia symptoms in people with dementia accessing ambulance services in the UK University of Nottingham; NIHR Advanced Fellowship, Portfolio

To design and test an acceptable and effective simulation-based staff-training to promote dementia awareness in ambulance staff and improve their confidence in managing dementia cases and quality of care, in the hope to reduce the number of new admissions to hospital emergency departments

Progress: Agreement to act as collaborator, awaiting result of Fellowship application

100

101 Publications

It is important that findings from research are disseminated. Recent publications arising from projects involving or supported by EMAS include:

1. The effects of a leaflet-based intervention ‘Hypos can strike twice’, on recurrent hypoglycaemic attendances, 999 EMS conference 2021

2. A national survey of ambulance paramedics on the identification of patients with end of life care needs; British Paramedic Journal 2020, vol. 5(3) 8–14 https://doi.org/10.29045/14784726.2020.12.5.3.8 Eaton-Williams P, Barrett J, Mortimer C and Williams J

3. An evaluation of the GoodSam volunteer first responder app for out-of-hospital cardiac arrest n two UK ambulance services. Resusitation 2020 Vol 155, Supp. 1 https://doi.org/10.1016/j.resuscitation.2020.08.022 Smith, Lall, Fothergill, Spaight, Perkins

4. The potential for bystander defibrillation for out-of-hospital cardiac arrest in two regions of the UK: Resusitation 2020 Vol 155, Supp. 1 https://doi.org/10.1016/j.resuscitation.2020.08.054 Smith, Lall, Fothergill, Spaight, Perkins

5. Mixed methods in pre-hospital research: understanding complex clinical problems: British Paramedic Journal 2020, vol. 5(3) 44– 51 https://doi.org/10.29045/14784726.2020.12.5.3.44 Whitley GA, Munro S, Hemingway P, Law GR, Siriwardena AN, Cooke D and Quinn T

6. The predictors, barriers and facilitators to effective management of acute pain in children by emergency medical services: a systematic mixed studies review. Journal of Child Health Care https://doi.org/10.1177/1367493520949427 Whitley GA, Hemingway P, Law GR, Jones A, Curtis F, Siriwardena AN (2020)

7. Predictors of effective management of acute pain in children within a UK ambulance service: a cross-sectional study. American Journal of Emergency Medicine 38: 1424–1430 https://doi.org/10.1016/j.ajem.2019.11.043 102 Whitley GA, Hemingway P, Law GR, Wilson C, Siriwardena AN (2020)

8. Risk Prediction Models for Out-of-Hospital Cardiac Arrest Outcomes in England. European Heart Journal. https://doi.org/10.1093/ehjqcco/qcaa019 Chen,Brown,Booth,Hawkes,Nolan,Mapstone,Fothergill,Spaight,Black,Perkins (2020)

9. Healthcare experiences of migrant and minority ethnic patients in Europe: a systematic scoping review. BMC Health Services Research 20:173. Phung VH, Asghar Z, Matiti M, Siriwardena AN (2020).

10. Electronic health records in ambulances: the ERA multiple-methods study. Health Serv Deliv Res 2020;8(10), https://doi.org/10.3310/hsdr08100 Porter A, Badshah A, Black S, Fitzpatrick D, Harris-Mayes R, Islam S, Jones M, Kingston M, LaFlamme-Williams Y, Mason S, McNee K, Morgan H, Morrison Z, Mountain P, Potts H, Rees N, Shaw D, Siriwardena N, Snooks H, Spaight R & Williams V.

11. Understanding how Eastern European migrants use and experience UK health services: A systematic scoping review. BMC Health Services Research (in press). https://doi.org/10.3310/hsdr08100 Phung VH, Asghar Z, Matiti M, Siriwardena AN.

12. Predictors of effective management of acute pain in children within a UK ambulance service: A cross-sectional study. Am J Emerg Med. 2019 Dec 9. pii: S0735-6757(19)30784-3. https://doi.org/10.1016/j.ajem.2019.11.043 Whitley GA, Hemingway P, Law GR, Wilson C, Siriwardena AN.

13. Ethical considerations in prehospital ambulance-based research: Qualitative interview study of expert informants. BMC Medical Ethics 2019; 20:88. https://doi.org/10.1186/s12910-019-0425-3 Armstrong S, Langlois A, Siriwardena AN, Quinn T.

14. The complexity of pain management in children, Journal of Paramedic Practice 11(11):466-468 https://doi.org/10.12968/jpar.2019.11.11.466 Whitley GA, Hemingway P, Law GR, Wilson C, Siriwardena AN.

103 15. The predictors, barriers and facilitators to effective management of acute pain in children by ambulance services: A systematic mixed studies review. In: College of Paramedics 3rd National Research Conference, 24-Sep-2019, Cardiff. Whitley, Gregory and Law, Graham and Jones, Arwel and Curtis, Ffion and Siriwardena, Niro and Hemingway, Pippa (2019)

16. Non-urgent calls to the ambulance service: Why do people call and what advice they are given? Poster presentation at European Society of Emergency Medicine conference 12-16 October 2019, Prague. Abstract reference Joanne Coster, Jon Nicholl, Alicia O'Cathain, Pre-Hospital / EMS / Out Of Hospital #18422 Abstract Book EUSEM 2019; https://eusem.org/past-congresses/2019 accessed 06.02.2020.

17. Whitley G, Pain management in child burn injuries – a hot topic. Standby CPD 2019:9(3), Class Professional Publishing.

18. Pre-hospital transdermal glyceryl trinitrate for ultra-acute intracerebral haemorrhage - data from the RIGHT-2 trial. Stroke (online first). Bath PM, Woodhouse LJ, Krishnan K, Appleton JP, Anderson CS, Berge E, Cala L, Dixon M, England TJ, Godolphin PJ, Hepburn T, Mair G, Montgomery AA, Phillips SJ, Potter J, Price CI, Randall M, Robinson TG, Roffe C, Rothwell PM, Sandset EC, Sanossian N, Saver JL, Siriwardena AN, Venables G, Wardlaw JM, Sprigg N (2019).

19. Developing new ways of measuring the quality and impact of ambulance service care: The PhOEBE mixed-methods research programme. Programme Grants Appl Res 2019;7(3). https://doi.org/10.3310/pgfar07030 Turner J, Siriwardena AN, Coster J, Jacques R, Irving A, Crum A, Gorrod HB, Nichol J, Phung VH, Togher F, Wilson R, O'Cathain A, Booth A, Bradbury D, Goodacre S, Spaight A, Shewan J, Pilbery R, Fall D, Marsh M, Broadway-Parkinson A, Lyons R, Snooks H, Campbell M.

20. Pre-hospital transdermal glyceryl trinitrate in patients with ultra-acute presumed stroke (RIGHT-2): An ambulance-based, randomised, sham-controlled, blinded, Phase 3 trial. The Lancet 2019 (online first) http://dx.doi.org/10.1016/S0140- 6736(19)30194-1 Bath PM, Scutt P, Anderson CS, Ankolekar A, Appleton JP, Berge E, Cala L, Dixon M, England TJ, Godolphin PJ, Havard D, Haywood L, Hepburn T, Krishnan K, Mair G, Montgomery AA, Muir K, Phillips SJ, Pocock S, Potter J, Price CI, Randall M, Robinson TG, Roffe C, Rothwell PM, Sandset EC, Sanossian N, Saver JL, Shone A, Siriwardena AN, Wardlaw JM, Woodhouse LJ, Venables G, Sprigg N et al.

21. Attitudes to cardiopulmonary resuscitation and defibrillator use: A survey of UK adults in 2017, Journal of the American Heart Association 2019;8: e008267. https://doi.org/10.1161/JAHA.117.008267 104 Hawkes C, Brown T, Booth S, Fothergill RT, Siriwardena AN, Zakaria S, Askew S, Williams J, Rees N, Ji C, Perkins G.

22. Interventions to reduce sickness absence among healthcare workers: A systematic review. International Journal of Emergency Services 2019. https://doi.org/10.1108/IJES-05-2018-0028 Simmons L, Jones A, Siriwardena AN, Bridle C.

23. Patient and clinician factors associated with pain treatment and outcomes: Cross-sectional study. American Journal of Emergency Medicine 2019; 37 (2): 266-271. https://doi.org/10.1016/j.ajem.2018.05.041 Siriwardena AN, Asghar Z, Lord B, Pocock, H, Phung VH, Foster T, Williams J, Snooks.

105 References

1. Bennett WO, Bird JH, Burrows SA, et al. Does academic output correlate with better mortality rates in NHS trusts in England? Public Health 2012;126 Suppl 1:S40-3. doi: 10.1016/j.puhe.2012.05.021

2. Ozdemir BA, Karthikesalingam A, Sinha S, et al. Research activity and the association with mortality. PLoS One 2015;10(2):e0118253. doi: 10.1371/journal.pone.0118253 3. Boaz A, Hanney S, Jones T, et al. Does the engagement of clinicians and organisations in research improve healthcare performance: a three-stage review. BMJ Open 2015;5(12):e009415. doi: 10.1136/bmjopen-2015-009415

4. CQC. Key lines of enquiry, prompts and ratings characteristics for healthcare services London: Care Quality Commission; 2018 [Available from: https://www.cqc.org.uk/sites/default/files/20171020-adult-social-care-kloes-prompts-and-characteristics- showing-changes-final.pdf accessed 25/10/2019 2019.

Clinical Audit

106 Part of ensuring good clinical governance, is through Clinical Audit. This provides the means by which EMAS ensures quality clinical care by making individuals accountable for setting, maintaining and monitoring standards. It is focussed around the three domains of quality - clinical effectiveness, patient safety and patient experience.

Clinical Audit and Research is led by our Clinical Audit and Research Unit which reports to the Clinical Governance Group. The department is responsible for developing EMAS’ clinical audit programme and ensures that all necessary support for the undertaking of clinical audit is readily available to staff and that progress is monitored.

The narrative and report below is the final position of Clinical Audits completed during this year 2020 – 2021.

For Clinical Audit, topics are divided into four main types: • Mandatory • Performance driven • Discretionary • Staff initiation

Clinical audit topics are selected according to priorities which may include some of the following considerations: 1. Is the area concerned of high cost, volume or risk to patients or staff? 2. Is there evidence of serious quality problems, eg patient complaints or high incident rates? 3. Is there good evidence available to inform standards, ie national clinical guidelines? 4. Is the problem concerned amenable to change? 5. Is there potential for impact on health outcomes? 6. Is there opportunity for involvement in a national audit project? 7. Is the topic pertinent to national policy initiatives? 8. Does the topic relate to a recently introduced treatment protocol? 9. Subjects raised by Risk Management and Untoward Incident Reporting

Audit / monitoring Type Timescale Note activity

107

Audits completed by Clinical Audit Department

• Cardiac arrest

➢ Return of Spontaneous Circulation including Utstein

➢ Survival to discharge Including Utstein.

➢ Resuscitation Bundle

• Stroke Mandatory – Monthly as Ambulance Clinical national per NHS Quality Indicators ➢ Diagnostic Bundle performance England (ACQIs) monitoring timetable ➢ Timeliness

• STEMI

➢ Care bundle,

➢ Timeliness

• Sepsis Care Bundle

These audits are reported on according to the timetable and the results published in the quarterly Clinical Effectiveness Report. Actions for improvement are included in the clinical effectiveness action plan. EMAS Clinical Discretionary Monthly Performance Audits completed by Clinical Audit Department: – local Indicators (ECPIs)

108 clinical audit • Asthma project • Epilepsy

• Febrile convulsion

• Hypo

• Intubation / ETCo2

• Pain Management in Dementia

These audits look at the results at county level and are produced, published and distributed each month. The audits are presented to Clinical Governance Group and discussed at the Clinical Improvement Group

• Report completed by accountable officer for controlled drugs. Controlled Drugs Local service Annual • Monitoring the use of controlled drugs in line with the duties of Usage Audit monitoring accountable officers.

• To investigate administration of fluids and oxygen for sepsis and recording of observations as per EMAS sepsis guidelines. This audit is now linked with Sepsis Discretionary the Sepsis ACQI.

Completed by the clinical audit manager.

Paediatric pain Discretionary Initial To investigate the assessment of pain in paediatric patients with dementia

109

Mental Health Discretionary Initial To Investigate the Usage and application of Mental Health Pathways Pathways

110

Appendix 5 – CQC registration

The Care Quality Commission conducted a planned inspection of EMAS which started in April 2019 and concluded in May 2019. In July 2019, we were delighted to announce that the Care Quality Commission (CQC) rated us as ‘Good’ overall and ‘Outstanding’ for caring. The change is great progress on our previous rating of ‘requires improvement’ in 2017, and is due to a huge amount of focussed work by colleagues across EMAS.

EMAS is fully compliant with the registration requirements of the Care Quality Commission and has arrangements in place for ongoing monitoring of compliance with these requirements and ensuring that actions required by the Care Quality Commission are implemented.

During 2020/21 the Trust applied for an amendment to its CQC registration to include surgical procedures in recognition of the increasing complexity and scope of clinical activity undertaken by our specialist crews or on our behalf by, for example, air ambulance services. This was approved in January 2021 and our registration status was updated accordingly.

111 Appendix 6 – Third Party Statements

The views and opinions expressed in this section are the opinions of third party stakeholders and do not necessarily reflect the views of EMAS.

Statement from the Co-ordinating Commissioner – NHS Derby and Derbyshire Clinical Commissioning Group (CCG) on behalf of East Midlands Associate CCGs

NHS Derby and Derbyshire Clinical Commissioning Group (CCG) is the Coordinating Commissioner for East Midlands Ambulance Service (EMAS) NHS Trust on behalf of commissioners in the East Midlands where EMAS is the urgent and emergency ambulance provider. In this role the CCG is responsible for monitoring the quality and performance of services at East Midlands Ambulance Service. We welcome the opportunity to provide the narrative on the Quality Account for 2020/21 on behalf of NHS Derby and Derbyshire, Leicester, Leicestershire and Rutland, North Lincolnshire, North East Lincolnshire, Nottinghamshire, Bassetlaw, and Northamptonshire Clinical Commissioning Groups.

General comments The Quality Account provides information on how the Trust has worked within the last year to make meaningful and sustainable improvements, and how it aims to continue to improve and maintain the quality and safety of the services that it provides for service users and their families even further.

The NHS will remember 2020/21 as the year it embarked on its response to the COVID-19 pandemic. The Trust’s response played an essential role in managing the pandemic and protecting the residents of the East Midlands by supporting the regional system response. The Trust put into practice its Emergency Planning, Resilience and Response plans and processes to support both its response to the pandemic and to maintain frontline services for all patients in need.

Commissioners have worked closely with the trust throughout this challenging year to gain assurances that the services delivered were safe, effective, and personalised to service users. The data presented has been reviewed and is in line with information provided and considered through the regular contractual performance and quality mechanisms.

Measuring and Improving Performance Commissioners note the progress and achievements on the quality priorities set out last year, which the Trust has rolled over into 2021/22 to further implement. There are clear examples and evidence to support statements of implementation and commissioners recognise that the Trust will concentrate on embedding these throughout the next year.

Commissioners agree that the Quality Account provides an overview of the Trust’s Strategy, vision, values, and work. These are now embedded within the Trust Strategy, as a way of integrating them more firmly into core business. Despite no inclusion of locally agreed CQUINs in the 2020/21 contract due to COVID- 19 demands, notable areas of service improvement include:

112

• Worked closely with acute hospitals to develop COVID-19 pathways for both ED and other areas/specialties. • Introduced the Clinical Development vehicles to provide support to staff when required. • Successfully delivered the flu vaccination campaign. • Worked with acute hospitals and other partners to develop and or expand alternative care pathways. • Introduced inappropriate conveyance audits and liaised directly with system partners to improve availability of and access to pathways • Supported the implementation Mental Health Triage Hubs in Derbyshire, Leicester and Leicestershire and Northamptonshire • Introduction of the Additional Capacity Clinical Operations Manager role to support staff and provide additional support and guidance around the role they play in supporting the wider health economy.

These achievements had a measurable impact on system performance and resilience and demonstrate the beneficial results of joint working between commissioners and the Trust.

Patient Safety The main category of incidents in 2020/21 relate to the quality of clinical care. This is a change from the previous year 2019/2020 when the highest category of Serious Incidents (SIs) was 'Delayed Response'. It is disappointing that the Trust do not elaborate on this in the Quality Account.

The Trust identified a risk in relation to cardiac arrest management. In mitigation the Trust rolled out the cardiac arrest strategy and developed the role of Cardiac Arrest Leader to reduce further recurrence. Commissioners acknowledge this proactive risk management approach and further monitoring will continue through contractual mechanisms.

During 2020/21 the Trust introduced regular proactive harm reviews to monitor the impact of both hospital handover delays and resulting delayed community responses. Commissioners welcome the review of over 900 cases across the region.

This Quality Account reassures commissioners that the Trust has in place stringent steps to learn from deaths of patients. Nonetheless, every death is unfortunate, and learning must continue to evolve and embed reflective practice amongst the organisation.

Patient Engagement The Trust reports a reduction of 74 formal complaints from the previous year with a total of 58 received in 2020/2021 across the East Midlands. These complaints are centred on three themes:

1. attitude of staff 2. quality of care 3. delayed response to the patient

113 Commissioners note these are the same themes as 2019/20. The Quality Account does not specify what actions were taken in 2019/20 to address these themes and what improvements, if any were delivered. EMAS has however contributed to two Provider Collaboration Reviews (PCR) in the Lincolnshire system in July 2020 and in Northamptonshire in October 2020 where positive feedback was received.

Staff Support and Wellbeing Commissioners recognise that the Trust has progressed several initiatives to enhance staff support and wellbeing including having 210 peer to peer /pastoral support network volunteers who are trained in supporting and signposting staff when needed over the past year.

CQC Commissioners acknowledge the ongoing hard work to sustain and improve the Trusts current CQC rating of ‘Good’ overall and ‘Outstanding’ for caring.

In August 2020, the Trust assured the CQC that Infection Prevention and Control (IPC) measures are in place. Again, in December 2020 the Trust assured the CQC that were plans in place to manage what was anticipated to be a challenging winter period.

Commissioners thank EMAS for the assurances given to CQC and subsequent improvements to services.

Furthermore, commissioners express their support of your goal to be rated ‘Outstanding’ overall in a future CQC inspection.

Additional comments This Quality Account 2020/21 statement provides assurance to members of the public that commissioners are committed to ensuring it assesses and provides a high quality of care across its services. This Account demonstrates the continued quality of services provided by EMAS by their ongoing commitment to their priorities and improvements through the year in all areas of quality against the difficult backdrop of working in the COVID-19 pandemic. For 2021-22, the Quality Account continues to drive quality improvements through a robust Quality Strategy with intended improvements in patient experience, safety, and clinical effectiveness to deliver the best outcomes for patients and staff. Within this statement DDCCG recognise and thank EMAS for working positively and collaboratively with commissioners and key stakeholders to ensure our patients receive a high quality of care at the right time and in the right care setting.

Commissioners look forward to working with the trust over the next year as health systems move towards integrated and collaborative partnerships across health and social care.

114 Name Brigid Stacey Chief Nurse Officer, Derby & Derbyshire CCG

Signature

Date 26th May 2021

Leicestershire County Council Health Overview and Scrutiny Committee

The Health Overview and Scrutiny Committee welcomes the opportunity to comment on the East Midlands Ambulance Service NHS Trust Quality Account for 2020/21. It is the Committee’s view that the Quality Account contains an accurate reflection of the Trust’s performance during the year. The Committee recognises that it has been an exceptionally demanding year for health services due to the COVID-19 pandemic and thanks all EMAS staff for their work and dedication during this difficult period.

The Committee notes from the Quality Account that an application from EMAS to be a COVID-19 vaccination hub was approved and that EMAS have been vaccinating their own staff. EMAS is commended on this.

The Committee is aware that during the pandemic initiatives were put in place to enable EMAS staff to better provide clinical advice and enable patients to access alternative care pathways and that this resulted in fewer than 50% of patients seen by EMAS being taken to hospital. The Committee welcomes the reassurance given in the Quality Account that these initiatives will continue after the COVID-19 pandemic has ended in order to keep Emergency Department attendances low.

It is acknowledged that due to the COVID-19 pandemic EMAS may not have been able to make as much progress in some areas as was intended for example with regards to the ‘Caring’ Quality Priority, and this issue is given due recognition in the Quality Account.

It is noted that due to the COVID-19 pandemic the Care Quality Commission (CQC) has not produced an inspection report on EMAS since July 2019 when it found the service to be ‘Good’ overall and ‘Outstanding’ for caring. This is unfortunate as CQC reports are an extremely useful barometer of a Trust’s performance and help guide the Committee as to which areas of the Trust’s work require further scrutiny. However, it is reassuring that the CQC have kept in close contact with EMAS, and CQC were assured in December 2020 of the plans in place for the 2020/21 winter period. At a public meeting in March 2021 Health Overview and Scrutiny Committee members also gained assurances regarding how the LLR health system had managed the winter period.

115 Over several years there have been delays in EMAS being able to handover patients at the Leicester Royal Infirmary Emergency Department and therefore it is helpful that the Quality Account provides an update on performance in this area, but disappointing to note that delays continued even though there were fewer attendances at Emergency Departments due to the COVID-19 pandemic. Nevertheless, it is pleasing that the Quality Account sets out the actions that have been taken by EMAS to address handover delays and mitigate the risk of harm.

The Quality Account states that EMAS have implemented Mental Health hubs across Leicester, Leicestershire and Rutland but provides no further details. The Committee would be interested in learning more about the hubs and where they are located.

The Committee notes that the Quality Account emphasises the importance that EMAS place on the patient voice and the Committee welcomes the success of the EMAS Patient Voice Forum and the details given in the Quality Account of how feedback from the Forum has influenced the work of EMAS.

The Quality Account clearly sets out that EMAS has put in place a Quality Strategy for 2020-2025 and in line with that the Quality Priorities for 2021-22 are that services are caring and compassionate, responsive to people’s individual needs, effective, and well led and safe.

Overall the Committee is of the view that the Quality Account contains a fair summary of the Trust’s work.

Lincolnshire County Council Health Overview and Scrutiny Committee

Introduction

The Health Scrutiny Committee for Lincolnshire reviews and scrutinises NHS-funded health services in the administrative county of Lincolnshire, which forms a substantial part of the Lincolnshire Division of the East Midlands Ambulance Service region.

COVID-19

The Committee recognises the significant impact of COVID-19 on emergency ambulance services and would like to record its thanks to all the EMAS staff, who have continued to provide emergency ambulance services during the challenges of the pandemic.

Progress on priorities for 2020-21

The Committee welcomes the fact that Priority 1 (Use of Patient Feedback) has included the establishment of a Patient Voice Group in Lincolnshire. The Committee would like to see the membership of Lincolnshire group strengthened during the coming year and confirmation of the reporting arrangements between the patient voice groups and the EMAS Board, so the patient voices can be heard and acted on.

116 This could be achieved by enabling patient voice groups to raise matters of concern directly with the EMAS Board.

The Committee notes that as part of Priority 2 (Meeting Individual Needs of Patients) there has continued to be an emphasis on reducing the rate of conveyance to A&E departments, for example, a non-conveyance rate of over 40% in February 2021. Robust clinical decision-making is key to the success of non-conveyance, so that both staff and patients can feel confident that the right treatment is being delivered in the right place at the right time. The Committee notes the 'missed opportunity' audits with their focus on patients taken to hospital unnecessarily. The Committee would like to see clinical audits of 'non-conveyed' patients, to provide reassurance that the treatment or advice they received out of hospital was appropriate to their clinical needs and wellbeing.

The Committee welcomes the piloting of cardiac arrest leaders in Lincolnshire as part of Priority 3 (Ambulance Clinical Quality Indicator Performance) activity. The Committee notes and supports the progress made with both Priority 4 (Continuous Staff Learning and Innovation) and Priority 5 (Improving Serious Incident Investigations).

Selection of Priorities for 2021-22

As stated in the section above, activity for Priority 1 (Use of Patient Feedback) should include strengthening patient voice groups; and the formal reporting arrangements should be considered, so that patient voice feedback is fully taken into account by the EMAS Board.

Promoting alternatives to inappropriate attendance at A&E is supported as part of Priority 2 (Meeting Individual Needs of Patients). However, the Committee believes that striving for targets could lead to patients who require attendance at A&E being inappropriately treated and suggests clinical audits of 'non-conveyed' patients as a source of evidence. The Committee acknowledges that there has been a wealth of learning during the pandemic and would like to see this shared so staff can feel confident in their clinical decision-making and patients can feel assured they are being treated appropriately. Staff appraisals would be expected to support this.

The Committee strongly supports Priority 3 (Ambulance System and Clinical Outcome Indicators). Liaison with acute hospitals is key to delivering improvement, so that handover delays are minimised, both to transfer patients to the appropriate hospital clinician as well as to release ambulances.

The Committee supports Priority 4 (Learning from Incidents) but would like to see more detail on how the learning, particularly during the pandemic, is going to be shared in practice. The Committee strongly supports Priority 5 (Managing Safeguarding Referrals).

Lincolnshire

117 The Committee welcomes the inclusion of specific information on Lincolnshire initiatives, such as cardiac arrest leaders, who have improved rates of return of spontaneous circulation; and pathways co-ordinators, who work to avoid inappropriate attendances at A&E. Reviews of patients being harmed as a result of hospital handover delays and response times are also welcome. The Committee would like to explore these topics with representatives from EMAS in the coming year.

It is expected that consultation on the Lincolnshire Acute Services Review will begin during 2021-22. As any service changes are likely to affect the demands on ambulance services, the Committee would expect EMAS to be involved in discussions on any significant service re designs.

Complaints and Compliments

The Lincolnshire Division has again recorded a reduced number of formal complaints, with a total of only eight. Both complaints and compliments are essential elements of patient feedback.

Non-Emergency Patient Transport

Although EMAS does not provide this service in Lincolnshire, the Committee notes the low level of complaints for the Trust's non-emergency patient transport services in Derbyshire and Northamptonshire.

Role of community first responders

The Committee would like the research, currently being undertaken by the University of Lincoln, on the role of community first responders in rural areas to be shared, as Lincolnshire has been supported for many years by the Lincolnshire Integrated Voluntary Emergency Service (LIVES), as well as services such as Lincolnshire Fire and Rescue.

Engagement with the Health Scrutiny Committee for Lincolnshire

The Committee received an information briefing in January 2021. In the coming year, the Committee like to receive a presentation on EMAS activities in the county, including some of the topics highlighted in this quality account.

Presentation of information

Although the required content of a quality account is not designed for members of public, the Committee believes that the document is as accessible as possible, and the inclusion of a glossary is welcomed.

Conclusion

118 We look forward to continued engagement with the Trust in the coming year and acknowledge that impacts of COVID-19 will continue to present challenges to the service.

Northamptonshire County Council Overview and Scrutiny Committee

The Health Scrutiny Committee for Nottinghamshire welcomes this opportunity to comment on East Midlands Ambulance Service Quality Account 2020/21

The committee recognise the exceptional pressure and workload on EMAS throughout this COVID-19 global pandemic year. The Trust is to be congratulated for the service levels maintained and care given throughout this unprecedented timeframe. The EMAS has responded to patients needs in an exemplary fashion putting aside personal risk to care for those who need it most in their moment of need. On top of the added pressures created by the pandemic, the committee recognise that front line staff have conducted their service whilst wearing additional layers of PPE for lengthy periods and despite this, the EMAS has maintained service levels to patients.

The committee note that the Service did not declare an emergency, indeed the EMAS has been able to take a leading role in national resilience even supporting services elsewhere across the country.

The committee congratulate the service for their collaborative approach not least with partnership working with blue-light colleagues.

The committee note that the EMAS trust applied, (and has been approved), for an amendment to its CQC registration to include surgical procedures in recognition of the increasing complexity and scope of clinical activity. This builds on the gains already made with the CQC in 2019.

The Committee notes the enormous stress and pressure that COVID-19 has brought to so many, not least those working tirelessly at the front line against this pandemic. While the report mentions increased support provision for staff mental health and wellbeing, we highlight that this is an area that will likely require more attention in the coming months and years.

Councillor Sue Saddington, Chair of Health Scrutiny Committee Councillor Matt Barney, Vice-Chair of Health Scrutiny Committee Nottinghamshire County Council

Comment from Nottingham City Council Health Scrutiny Committee

119 The Nottingham City Health Scrutiny Committee (the Committee) welcomed the opportunity to discuss its Quality Account 2020/21 with colleagues from East Midlands Ambulance Service (EMAS) and is pleased to be able to comment on it.

As the Committee has not undertaken any scrutiny of EMAS during 2020/21, its comments are restricted to planned priorities for 2021/22.

The Committee recognises the pressures of the pandemic on the organisation, both in terms of service provision and the impact on patients and staff, and how this will have influenced the way services have been provided in 2020/21. While, these have been challenging times, it was refreshing to hear that some of the changes brought in to adapt to the pandemic will continue, given their positive impact, eg introducing the role of specialist paramedics who are able to prescribe and liaise with GPs to support patients without COVID symptoms.

The Committee welcomes the Trust’s vision to develop its quality improvement strategy based on delivering caring and compassionate, responsive, effective, well- led and safe services. These aspirations also underpin the work of the Committee which is committed to using its scrutiny powers to meet the needs of services users in the best possible way, and to achieve the best possible outcomes for them.

The Committee also welcomes the Trust’s commitment to providing more diverse ambulance teams (eg including ambulance nurses) and reducing the pressure on Emergency Departments by increasing the opportunities to deliver patients to the service most appropriate for their needs.

The Committee looks forward to working with EMAS in the future on the specific needs and experiences of people living and working within Nottingham city.

24 May 2021

Healthwatch East Midlands Regional Group of local Healthwatch including Derby, Derbyshire, Leicester, Leicestershire, Lincolnshire, Northamptonshire, Nottingham, Nottinghamshire and Rutland

Healthwatch Lincolnshire:

Healthwatch Lincolnshire are pleased to receive the Quality Accounts for 2020/21 and much progress has been made during this difficult time.

The feedback Healthwatch Lincolnshire receives regarding ambulance services is positive and thankful towards the great work being carried out by EMAS staff.

We recognise that geography and demographics across our region is very complex and, in some places, can be very challenging. We do note the improvements on waiting times for ambulances and would welcome continued collaboration with hospitals trusts to decrease handover delays with significant lost time as we move

120 forwards with the Integrated Care System, learning from progress made during the pandemic.

We very much support the priority to listen to more patients, carers, and families to integrate the patient voice into all aspects of EMAS work. Healthwatch will continue to provide EMAS with the patient voice to use the feedback to improve their services and we welcome more opportunities to do so and to hear what difference patient feedback has made to the delivery of emergency care in Lincolnshire.

Healthwatch Rutland:

We thank East Midlands Ambulance Service for inviting comment from Healthwatch Rutland on the 2020/2021 Quality Account. We recognise the extraordinary challenges under which staff have operated over the year due to the impact of the pandemic and would like to extend our thanks to all Trust staff for their hard work and dedication.

The Trust reports 59,759 hours lost due to handover delays, some 32,329 fewer than in the previous period, showing significant improvement. However, we would urge a clear focus to be placed on maintaining this improvement during the restoration and recovery period as attendances at emergency departments potentially increase again.

With continuous improvement goals and performance against them being the foundation of a quality account, we are disappointed that there is little indication of how staff career progression and retention has fared during the pandemic period, or how it will be promoted during the next year.

We welcome the continuation into 2021/22 of improvement priority 1 to listen to and use feedback from patients, carers and families to continually improve services.

Healthwatch Nottingham and Nottinghamshire:

Healthwatch Nottingham and Nottinghamshire (HWNN) thanks EMAS for their Quality Account.

We were pleased to read that EMAS has increased membership of your Nottinghamshire and Derbyshire Patient Voice Groups and initiated a new group in Lincolnshire and that these groups have supported the development of the Trust’s Quality Improvement Strategy, supported the implementation of a bereavement booklet and a patient advice leaflet for safe discharge. We would be interested to know how these groups supported these activities and in what way their experiences were incorporated into the strategy, booklet and leaflet.

It is also encouraging to read that the total number of compliments both internal and external has increased to 2,636 compared to 1,805 in the previous year. We would be interested to know what the main themes of these compliments were and what proportion were from Nottingham and Nottinghamshire. Similar detail about the complaints would also be helpful.

121

It is also positive to read that fortnightly Learning from Events sessions open to all staff and volunteers are being held and that learning from complaints, compliments, incidents, audits and inquests is incorporated into training and development programmes and disseminated through clinical bulletins and regular staff briefings, Learning from Events sessions and communications.

HWNN welcomes the aim to expand patient voice groups in terms of diversity of membership and geographical representation, increase ambassador roles, pilot young person’s engagement and look forward to receiving an update on this in next year’s Quality Account.

Healthwatch North & North East Lincolnshire response to the Annual Quality Accounts 2020/21

Healthwatch North & North East Lincolnshire accepts the Quality Accounts for the forthcoming year and acknowledges the key priorities that EMAS has identified to focus on. In addition to this Healthwatch applaud the efforts of all staff and volunteers to improve services offered to those that live within North & North East Lincolnshire, during the COVID-19 Pandemic. We hope that we can develop our working partnership into 2021/22.

You have identified that you still have work to do on capturing more feedback from patients, carers and families. Healthwatch North & North East Lincolnshire would like to see this as a priority for across Northern Lincolnshire.

Improvements have been made and non-conveyances to hospital are improving. The impact this has on patients has improved their wellbeing.

However, the Quality Accounts does not distinguish North & North East Lincolnshire from The County of Lincolnshire or the work that you yourselves carry out with the Northern Lincolnshire & Goole Foundation Trust. This does not allow us to make specific comments on your work locally. EMAS’ priorities for the next 2 years are clear and understandable and as Healthwatch we would like to offer our support to help you achieve your goals. Lastly we would like to thank your staff teams for all their hard work during the pandemic.

Yours sincerely,

Tracy Slattery Carrie Butler Delivery Manager Delivery Manager Healthwatch North East Lincolnshire Healthwatch North Lincolnshire

122

123 Appendix 7 – EMAS Trust Board

The main role of the EMAS Trust Board is to guide the overall strategic direction of our ambulance service, to ensure we can meet our current challenges, establish and achieve our objectives and plan effectively for the future.

Our Trust Board has overall corporate responsibility for how EMAS runs. Our Trust Board is led by our Chairman and comprises of executive and non-executive directors.

Executive directors are responsible for managing our affairs on a day-to-day basis, while non-executive directors provide essential balance, with their skills and expertise in the public and private business sectors to complement those of our executive directors. Chairman Pauline Tagg MBE

Non-Executive Directors Stuart Dawkins, Gary Brown, Karen Tomlinson, Vijay Sharma and William Pope

Associate Non-Executive Director Jane Ide (until 31 December 2020), Perminder Heer (from 1 August 2020)

Chief Executive Richard Henderson

Director of Operations Ben Holdaway

Medical Director Dr Leon Roberts

Director of Quality Improvement & Patient Safety Nichola Bramhall

Director of Human Resources and Organisational Development Kerry Gulliver

Director of Finance Mike Naylor

Director of Strategy and Transformation Will Legge

124

Director’s responsibilities in respect of the Quality Account

The EMAS Trust Board has been involved in identifying the quality indicators, agreeing the content and endorsing the content of this Quality Account. We have developed our quality priorities and indicators in conjunction with our stakeholders and our staff. Non-executive directors continue to play a pivotal role in providing challenge and scrutiny, assessing our performance and contributing to our future strategy.

Statement of directors' responsibilities in respect of the quality account

NHS trusts are required under the Health Act 2009, National Health Service (Quality Accounts) Regulations 2010 and National Health Service (Quality Account) Amendment Regulation 2011 to prepare Quality Accounts for each financial year. The Department of Health has issued guidance on the form and content of annual Quality Accounts (which incorporate the above legal requirements). In preparing our Quality Account, the Trust Board has ensured that:

• The Quality Account presents a balanced picture of the Trust’s performance over the period covered. • The performance information reported in the Quality Account is reliable and accurate. • There are proper internal controls over the collection and reporting of the measures of performance included in the Quality Account, and these controls are subject to review to confirm that they are working effectively in practice. • The data underpinning the measures of performance reported in the Quality Account is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review. • The Quality Account has been prepared in accordance with Department of Health guidance.

The directors of the Trust Board confirm to the best of their knowledge and belief that they have complied with these requirements in preparing this Quality Account. This has been confirmed through a resolution of the Trust Board.

125 Glossary

A&E Accident and Emergency, also referred to as A&E, is a hospital or primary care department that provides initial treatment to patients with a broad spectrum of illnesses and injuries, some of which may be life-threatening and require immediate attention. Also referred to as ED or emergency department.

ACQI Ambulance Clinical Quality Indicators, a set of 11 indicators introduced to the Ambulance Service by the government from 1 April 2011 as measures of clinical quality. These are now divided into System Indicators and Clinical Outcomes.

AMPDS Advanced Medical Priority Dispatch System is a medically-approved, unified system used by EMAS to dispatch appropriate aid to medical emergencies including systematized caller interrogation and pre-arrival instructions.

Audit A continuous process of assessment, evaluation and adjustment.

Board EMAS Trust Board of Directors made up of executive and non-executive members responsible for all that EMAS does.

Clinical Assessment Team (CAT) A paramedic or nurse triage advisor who telephones lower priority patients to carry out a full assessment of the patient’s condition and then suggest the best treatment, such as being cared for at home, being referred to a GP, pharmacy or community- based care service.

Clinical commissioning group (CCG) Clinical commissioning groups (CCGs) are NHS organisations set up by the Health and Social Care Act 2012 to organise the delivery of NHS services in England.

Capacity Management Plan (CMP) A plan designed to ensure that resources are prioritised to the most clinically urgent calls during times of sustained high pressure.

Commissioners NHS organisations that effectively purchase services from EMAS, based on the identified health needs of their local population. NHS Derby and Derbyshire Clinical Commissioning Group is the ‘lead commissioner’ for EMAS. That is, they (on behalf of all the CCGs in our area) negotiate what level of income EMAS will receive – and, alongside this, what quality measures we are expected to achieve as set out in our service level agreement.

CQC

126 The Care Quality Commission (CQC) regulates all health and adult social care services in England, including those provided by the NHS, local authorities, private companies or voluntary organisation. It also protects the interests of people detained under the Mental Health Act.

CQUIN Commissioning for Quality and Innovation, known as CQUIN, is a payment framework that makes a proportion of NHS service providers' income conditional on quality and innovation. Its aim is to support the vision set out in High Quality Care for all of an NHS where quality is the organising principle. The framework was launched in April 2009 and helps ensure quality is part of the commissioner-provider discussion everywhere.

DCA Double crewed ambulance – the vehicle which responds to patients and in the majority of cases will transport patients to hospitals.

EMAS East Midlands Ambulance Service, also referred to as EMAS, is part of the NHS and provides emergency and urgent for the six counties of Derbyshire, Leicestershire, Rutland, Lincolnshire (including north and north east Lincolnshire), Northamptonshire and Nottinghamshire. Patient Transport Services are provided in Derbyshire.

Enews Weekly newsletter to all EMAS staff.

EOC Emergency Operations Centre (control) at East Midlands Ambulance Service. One based in Nottingham and one based in Bracebridge, Lincoln. The centres receive the emergency and urgent 999 calls and dispatch ambulance crews to them or give ‘hear and treat’ advice via the Clinical Assessment Team (paramedics and nurses who work in the control centre).

FRV Fast response vehicle – a car normally manned by a solo clinician.

IG Information governance is the way by which the NHS handles all organisational information, the personal and sensitive information of patients and employees. It allows organisations and individuals to ensure that personal information is dealt with legally, securely, efficiently and effectively, in order to deliver the best possible care.

NHS National Health Service. Established in 1948 to provide free state primary medical services throughout the United Kingdom.

NICE

127 National Institute for Health and Clinical Excellence. The health technology assessment body in the UK providing guidance to clinicians relating to authorised treatments, devices, diagnostics and techniques.

PALS Patient Advice and Liaison Service – offers confidential help, advice, support and information and are responsible for any compliments and complaints.

ROSC Return of Spontaneous Circulation. Following a period when the heart stops, providing life support is aimed at restoring the body’s circulation.

SI Serious incident

STEMI ST Elevation Myocardial Infarction is a heart attack.

STP Sustainability and Transformation Partnerships are the NHS and local councils’ development and implementing of shared proposals to improve health and care in every part of England.

Ulysses EMAS’ computer system for recording compliments and concerns from service users, friends and family.

128 Contact details

We welcome your comments about our Quality Account.

Please contact us using the details below:

East Midlands Ambulance Service NHS Trust Trust Headquarters 1 Horizon Place Mellors Way Nottingham Business Park Nottingham, NG8 6PY

Telephone 0115 884 5000 Email [email protected] Visit www.emas.nhs.uk Twitter Twitter: @EMASNHSTrust Facebook: Facebook: EMASNHSTrust

To receive this report in other formats, such as large print, audio or another language, please call our Communications team via 0115 884 5000.

We welcome feedback from patients and the public, whether it is to say ‘thank you’ for a positive experience, or if there’s something that we need to get better at. We use this feedback to help us to improve our service.

You can contact the Patient Experience Team at:

Email: [email protected]

Telephone: 0333 012 4216 (local rate)- staffed between 10.00 – 14.00 hours, Monday to Friday. Messages can be left out of hours.

Mail: using the Trust Headquarters address above.

129