Audit Committee Ambulance Services in Wales Inquiry July 2009 The National Assembly for Wales is the democratically elected body that represents the interests of Wales and its people, makes laws for Wales and holds the Welsh Government to account. An electronic copy of this report can be found on the National Assembly’s website www.assemblywales.org Further hard copies of this document can be obtained from: Audit Committee National Assembly for Wales Cardiff Bay CF99 1NA Tel: 029 2089 8617 Fax: 029 2089 8021 Email: [email protected] National Assembly for Wales Audit Committee Ambulance Services in Wales Inquiry July 2009 Ambulance Services in Wales Inquiry Contents Chair’s Foreword 4 Introduction 5 The eight minute standard 8 Rapid Response Vehicles 9 Transport of patients by other emergency services 11 Intelligent targets 12 Advanced Paramedic Practitioners 13 Handovers 15 Data terminals 16 Handover targets 17 Making best use of resources 18 Ambulance officers 19 Restocking 21 Sharing best practice 21 Addressing geographical variations 22 Staffing levels at emergency departments 23 The staff experience 24 WAST financial position 25 Re-organisation of the NHS 26 1 Annexes Audit Committee Record of Proceedings 21 January Annex 1 2009 Audit Committee Record of Proceedings 11 March Annex 2 2009 Audit Committee Record of Proceedings 30 April 2009 Annex 3 Audit Committee Record of Proceedings 4 June 2009 Annex 4 Audit Committee Record of Proceedings 18 June Annex 5 2009 AC(3) 08-09 (p1) Unison – Ambulance Services in Annex 6 Wales AC(3) 08-09 (p2) British Paramedics Association – Annex 7 Ambulance Services in Wales 2 Committee Membership Jonathan Morgan Chair Cardiff North Welsh Conservative Lorraine Barrett Mike German Janice Gregory Cardiff South and Penarth South Wales East Ogmore Labour Welsh Liberal Democrats Labour Lesley Griffiths Irene James Bethan Jenkins Wrexham Islwyn South Wales West Labour Labour Plaid Cymru Huw Lewis Nick Ramsay Janet Ryder Merthyr Tydfil and Rhymney Monmouth North Wales Labour Welsh Conservative Plaid Cymru 3 Chair’s Foreword Since the National Assembly for Wales voted in favour of an inquiry into the Welsh Ambulance Services NHS Trust in July 2006, the Audit Committee has taken a keen interest in the performance of the Ambulance service. But despite two Committee reports on the underperformance of the Trust, the Committee is not convinced that progress is being made and remains unhappy with unscheduled care provision. The Trust has undergone a transformational change in recent years that has gone some way to modernising the delivery of pre-hospital care in Wales but further improvement is still needed. The Committee is concerned that targets designed to ensure a prompt response to emergency 999 calls are not being met consistently and at times, performance falls well below the required level. The Committee is also concerned that performance has been adversely affected by the Trust’s efforts to make efficiency savings. Further concerns relate to the bullying culture evident in the Trust which is undermining the achievements of staff and must be addressed as a priority. But the Ambulance service does not work in isolation. Lengthy delays to handovers at accident and emergency units can mean that paramedics are queuing with patients in corridors and unavailable to answer 999 calls. For the patient in an A&E Department a lengthy wait is unacceptable. For the patient in the community awaiting a response to a 999 call, the situation could be fatal. It is of the utmost importance that the NHS in Wales works to improve the process from the ‘front door’ to the ‘back’, with joined up working and intelligent systems that have both the capacity and the tenacity to enable staff to provide first class care. This report examines the pre-hospital care provided by the Welsh Ambulance Services NHS Trust and the handover process when paramedics transfer the care of a patient to hospital staff. The Committee has previously made recommendations about delayed transfers of care which occur when patients are discharged from hospital, and will be examining other aspects of the patient journey in future reports. It is hoped that the Welsh Assembly Government will take the opportunity of the forthcoming re-organisation of the NHS to modernise the delivery of care across the whole system. However, the re-organisation should not be seen as the solution in itself and work on improving the performance of the Wales Ambulance Service NHS Trust must be carried out in earnest. I would like to thank the witnesses who gave evidence to this inquiry. The passion and dedication of those individuals was apparent throughout and the Committee is grateful for their time and efforts. Jonathan Morgan, Chair, Audit Committee 4 Introduction 1. The Welsh Ambulance Service NHS Trust is the frontline provider of pre- hospital unscheduled care in Wales. The all Wales service responds to emergency 999 calls in order to save lives and provide emergency care to patients. The Audit Committee commends the dedication and hard work of all staff of the ambulance service who strive each day to ensure that the patients they see receive the care they need. 2. However, concerns regarding the Welsh Ambulance Service NHS Trust have been ongoing for sometime. Accusations of bullying and poor morale were coupled with poor performance against the Trusts performance targets. In times of particular pressure, the already overstretched service was brought close to breaking point with reports of ambulances queuing outside emergency departments and patients waiting for unacceptably long periods for an emergency response. 3. In July 2006, the National Assembly for Wales voted for an inquiry into ambulance services in Wales, to be led by the Auditor General for Wales. The Auditor General for Wales published his report on the inquiry in December 2006. The inquiry concluded that there were longstanding and severe problems throughout the Welsh Ambulance Service NHS Trust. In March 2007, the predecessor Audit Committee reported on its own investigation into the issues. 4. In June 2008, the Auditor General for Wales reported on his follow up review into the Ambulance Services in Wales. That review found that although there was evidence of positive improvements in the Trust since December 2006, some difficult problems remained. These problems were judged by the Wales Audit Office as symptomatic of the process of transformational change. The Audit Committee report of October 2008 reflected this view and recognised that although there was a need to make rapid and sustained progress, it would take time to deal with some of the organisational and systemic challenges that faced the Trust. 5. In December 2008, the Welsh Assembly Government responded to the Audit Committee report. The Audit Committee considered the response in January 2009 and sought advice from the Auditor General for Wales.1 The Committee was concerned that progress was not being made quickly enough with regard to the issues highlighted in its earlier reports. It decided to seek further evidence from Paul Williams, Director-General of Health and Social Services and Accounting Officer in the Welsh government, and Alan Murray, Chief Executive of the Welsh Ambulance Services NHS Trust. 6. The Auditor General for Wales issued his report ‘Ambulance Services in Wales – further update to the National Assembly for Wales’ Audit 1 AC(3)-01-09 (p2), (p3) 5 Committee’ ahead of the Audit Committee meeting on 11 March 2009, in which Paul Williams and Alan Murray gave evidence to the Committee. 7. On 23 April, the Auditor General for Wales published his report ‘Unscheduled Care – patient handovers at hospital emergency departments’. 8. Following consideration of the report on handovers,2 the Audit Committee launched an inquiry into ambulance services in Wales in order to examine the wider issues effecting performance of the trust. 9. The Committee took oral evidence from: 16 March 2009 • Alan Murray, Chief Executive, Welsh Ambulance Service NHS Trust • Tim Woodhead, Director of Finance, Welsh Ambulance Service NHS Trust • Paul Williams, Director-General of Health and Social Services, Welsh Assembly Government • Simon Dean, Director of Service Delivery and Performance Management, Welsh Assembly Government 4 June 2009 • Dave Galligan, Head of Health, Unison Wales • Tina Donnelly, Director, Royal College of Nursing • Andrew Evans, Professional Officer, Royal College of Nursing • Professor Malcolm Woollard, Chair of the College of Paramedics 18 June 2008 • Jon Falcus, Directorate General Manager, Wrexham Maelor Hospital • Judith Rees, Deputy Directorate General Manager, Wrexham Maelor Hospital • Meredith Gardner, Directorate Manager, University Hospital of Wales • Jennie Palmer, Senior Team Leader Nurse, Emergency Unit, University Hospital of Wales • Alan Murray, Chief Executive, Welsh Ambulance Service NHS Trust • Tim Woodhead, Director of Finance, Welsh Ambulance Service NHS Trust 2 AC(3)-06-09 (p2) 6 • Paul Williams, Head of Health and Social Services, Welsh Assembly Government • Simon Dean, Director of Service Delivery and Performance Management, Welsh Assembly Government 10. Written evidence was also received from Professor Malcolm Woollard and Dave Galligan. 7 The eight minute standard 11. The Welsh Ambulance Service NHS Trust has a target to respond to category A immediately life threatening calls within eight minutes at least 65 percent of the time. From March 2005 – April 2007 the target eight minute response