Scrutiny at Eden

999 - Ambulance Service!

A Scrutiny Review into the North West Ambulance Service Coverage and Emergency Response Times in Contents

1. Summary 3 1.1 What we wanted to do 3 1.2 How we did it 3 1.3 What we found out 3 1.4 Where we go from here 4 1.5 Summary of recommendations 5 2. Background 7 2.1 Membership and Terms of Reference 7 2.2 Background to North West Ambulance Service 7 2.3 Background to the Ambulance Service in 8 2.4 Background to the Ambulance Service in Eden District 10 2.5 Background to Eden District 11 2.6 Automated External Defibrillators 11 3. Methodology 12 3.1 Desktop Research 12 3.2 Summary of Review Meetings 12 3.3 Surveys 14 3.4 Letters 14 3.5 Media Releases 14 4. Addressing the Scope: Evidence Gathered 15 4.1 To review the Emergency Ambulance Service within 15 Eden District and in the wider context of Cumbria 4.2 Emergency Ambulance Coverage in Eden District 15 4.3 Response Times 16 4.4 Developing a Rural Response Time Target 18 4.5 Community First Responders in Eden District 19 4.6 Alston Ambulance Agency 20 4.7 Automated External Defibrillator (AED) Towns 21 4.8 Raising Awareness 22 4.9 BEEP Fund/Doctors 23 5. Conclusions 24 5.1 Emergency Vehicle Coverage in Eden District 24 5.2 National Response Targets 24 5.3 Community First Responders 25 5.4 Automated External Defibrillators (AED’s) 26 5.5 Raising Awareness 26 5.6 Alston Moor 26 5.7 The Scrutiny Review in the Wider Context 26 6. Recommendations 28 Scrutiny Study of North West Ambulance Emergency Service in Eden District Coverage and Response Times

1. Summary

1.1 What we wanted to do

Whilst Cumbria County Council has the statutory duty to scrutinise health services we are aware that, because of the size of the county it cannot usually look at detailed local issues. It was therefore decided, and agreed with the county, that Eden would look at health services in the district to make sure we are happy with the services provided. Following requests from residents and other factors it was decided to begin by investigating the emergency ambulance service in the district.

1.2 How we did it

 We began by holding four pre-scoping meetings to get up to speed with the current service  We met and/or spoke with staff, users of the service and contacted all the parish councils in the district  We also met with representatives of North West Ambulance Service, Cumbria Clinical Commissioning Group and Alston Ambulance Service  We talked to representatives of Mountain Rescue, Community First Responders and the BEEP (Birbeck Emergency Equipment for Patients) service

1.3 What we found out

 There was a discussion in the House of Commons on 21 January 2013 when the Secretary of State, Anna Soubry, called for an urgent review of the Ambulance Services  That everyone who contacted us or we spoke to said this was not about the ambulance crews, who were in their opinions, professional, caring and competent and wished their sentiments to be reflected in this report  The current ambulance service data is designed to meet national response times rather that patient outcomes  Response times in Eden district (and the rest of rural Cumbria) is significantly lower than urban areas and therefore affect outcomes  The current national commissioning arrangements do not suit rural areas such as Eden district (nor the rest of rural Cumbria)  That NWAS propose to make changes to the night time emergency ambulance cover in Cumbria. This will mean the loss of Penrith’s Rapid Response Vehicle (RRV) for 5 hours per night.  There are a number of issues in the wider health organisation that impact on the ambulance service such as hospital turnaround times, patients requiring specialist treatment at hospitals outside of the county and emergency calls made when patients cannot see their GP’s or ‘Cumbria Health on Call - CHOCdocs’ (out of hours GP service) quickly.  Community First Responders are a key part of the Ambulance Service in Cumbria and especially in Eden district and should be treated in a similar fashion to the Mountain Rescue Service in terms of VAT exemption/compensation.  That Eden district needs to keep its ambulance vehicles and staff within the area

1.4 Where we go from here

 We are asking our MP to take four of our recommendations to the Health Minister to request that the Government investigate the national policies.  We are asking the County Council Health Scrutiny to monitor NWAS and the recommendations the Eden Review Group has made.  We have asked NWAS to consider some recommendations made and return their comments to us.  We will consider progress with our recommendations in November 2014 and April 2015. 1.5 Summary of Recommendations

Recommendation Responsible Body Financial Implications Delivery Risks to Timescale Delivery/Officer Comment 1. That the Government investigate the Government None March 2015 consistent failure to achieve the national target times in rural areas 2. That more emphasis should be placed on Government None March 2015 nationally reporting patient outcomes CCG rather than response times 3. A holistic approach to healthcare is Government None March 2015 required as there are pressures on CCG NWAS which are beyond their control such as queuing at A&E departments and problems with the Out of Hours GP service 4. Community First Responders are a key Government None March 2015 part of the Ambulance Service in Cumbria and especially in Eden district and should be treated in a similar fashion to the Mountain Rescue Service in terms of VAT exemption/compensation.

5. NWAS should report the contribution NWAS None March 2015 made by CFR’s to their national response targets and their contribution to patient outcomes 6. A limited extension of the CFR’s remit NWAS None March 2015 should be considered to include attending fall patients where there is low risk to the Recommendation Responsible Body Financial Implications Delivery Risks to Timescale Delivery/Officer Comment responders 7. Re-advertising the ‘Point Taken’ initiative NWAS None December and offering it in different formats to 2014 enable more remote rural residents the chance to register their properties in case of emergency

8. Using parish/community newsletters to EDC Some newsletters December inform residents of what to expect from Organisation and require purchase of 2014 NWAS when calling in an emergency and External Relations PH space in their magazine. what NWAS expects from the caller Costs would be minimal. 9. The key service centres in Eden to be EDC Finance for AED’s could March 2015 promoted as AED Towns and Heartstart Organisation and be grant financed. training to be offered to as many External Relations PH Heartstart training is residents including school pupils and free. businesses as possible 10 To monitor the RRV situation should the CCC Health Scrutiny None March 2015 proposals be brought up again next year 11 Councillor Libby Bateman be supported in CCC Health Scrutiny None her bid to have a mobile ‘app’ for public AED locations to be rolled out nationally 2. Background

2.1 Membership and Terms of Reference

2.1.1 Six members were nominated to the Task and Finish Group. They were: Councillors: Patricia Godwin Neil Hughes Keith Morgan Sheila Orchard Joan Raine (Chairman); and Malcolm Temple 2.1.2 Although Cumbria County Council has the statutory duty for health issues, this topic affects all residents in and visitors to Eden district and was a topic raised by the public during consultations for the 2013/14 Scrutiny Work Programme. 2.1.3 The Group agreed the following Terms of Reference: a) To examine the current performance of the North West Ambulance Service (NWAS) against Category R1 (immediate life threatening calls) and Category R2 (less critical but still urgent) calls. b) To understand the limitations/obstacles that prevent achievement of targets and consider if/how these can be overcome. c) To examine the pattern of Community First Responders (CFR’s) in the district and if/how to develop the scheme. d) To monitor the new approved proposals for the Alston Ambulance Service during the review period.

2.2 Background to North West Ambulance Service

2.2.1 The North West Ambulance Service NHS Trust (NWAS) was established on 1 July 2006 following the merger of the Cumbria, Greater Manchester, Lancashire and Mersey Regional ambulance trusts. 2.2.2 NWAS provides services to a population of around seven million people across a geographical area of approximately 5,400 square miles. The Trust handles in the region of one million emergency calls each year and undertakes approximately 1.2 million patient journeys. 2.2.3 The Trust employs just under 5,000 staff who operates from 109 sites across the region and provides services for patients in a combination of rural and urban communities, in coastal resorts, affluent areas and in some of the most deprived inner city areas in the country. NWAS also provide services to a significant transient population of tourists, students and commuters. 2.2.4 Ambulance services nationally are required to achieve 75% attendance in 8 minutes from the call connect point for immediate life threatening conditions classed as Red 1 (R1) and 75% in 8 minutes attendance from point of triage for all other Red 2 (R2) emergencies. There are no national targets for Green (G1 and G2) categorised calls. 2.2.5 Red 1 - known as immediate threat to life are conditions which may require defibrillation (ie cardiac arrests and respiratory problems). Red 1 calls are timed the moment the call is connected to the Trust’s switchboard and the clock stops once the first resource arrives at the scene. 2.2.6 Red 2 - known as serious and possible life threatening (ie strokes, and unconsciousness). Red 2 calls are timed from the moment the call taker has the chief information from the caller and the first resource arrives at the scene. 2.2.7 A19 - is an amalgamation of R1 and R2, it is one target. Within this amalgamation, approximately 10% of calls are R1 and the remaining 90% are R2. The Trust is required to attend to 95% of R1 and R2 calls within 19 minutes. 2.2.8 NWAS is commissioned to achieve the targets annually for the whole of the North West region rather than individual counties or areas. The Trust exceeded the national target last year, reporting a Red1 (8 minute) response of 76.6% against the 75% national target. 2.2.9 Although there are no national targets for Green calls, NWAS has implemented its own:  Green 1 calls - the aim is to reach the patient within 20 minutes  Green 2 calls have an NWAS implemented response time of 30 minutes Category Green calls are considered serious but non-life-threatening.  Category Green 3 and 4 calls do not have a standard and generally may be referred to another healthcare pathway or are GP/Hospital requests for non- urgent transportation 2.2.10 The Care Quality Commission undertook a Review of Compliance in April 2012 that focussed on 999 and urgent care in Cumbria and Lancashire. Six ‘Outcomes’ were investigated and all passed. Below is an extract from the report regarding emergencies in rural areas: “NWAS monitored the time taken for its ambulances to respond to Category A (now Category R1) calls and had improved its response times in the last year to continually meet and often exceed the national target. Apart from rapid response vehicles (RRV) and ambulances reaching the scene of an incident in a rural setting, where distance can delay the arrival of an ambulance, Community First Responders (CFRs) and public access defibrillators are used to provide a faster response time to victims of heart attacks where they can begin first aid. CFRs are volunteers from the local community trained to respond to emergency 999 calls in conjunction with the ambulance service. 2.2.11 When drafting the final report the Group was informed that another CQC inspection of NWAS would take place in July 2014. Further details can be found at the end of the report.

2.3 Background to the Ambulance Service in Cumbria

2.3.1 Cumbria is part of the Trust’s Cumbria and Lancashire operational area. 2.3.2 NWAS has consistently underachieved on the national target response times in Cumbria despite investment in resources. See Appendix A 2.3.2 NWAS Resources in Cumbria

2.3.3 There are 17 ambulance stations located within the county of Cumbria. 2.3.4 There are 54 emergency ambulances, 15 Rapid Response Vehicles (RRV) and two Advance Paramedic cars located in the county. 2.3.5 The county also has 164 Paramedics, 144 Emergency Medical Technicians (EMTs), 8 Senior Paramedics and 6 Advanced Paramedics. 2.3.6 The operational team for Cumbria and some of East Lancashire and Fylde comprises of 7 staff. There are also two admin clerks and a limited number of support staff. 2.3.7 The emergency operations centre for Cumbria is located in Broughton near Preston, although there are two others located in Manchester and Liverpool. 2.3.8 Historically NWAS was not achieving targets in Cumbria due to resource levels. Since 2007 resources have been increasing and according to NWAS, this has helped significantly in terms of performance.

2.3.9 Activity and Performance

2.3.10 From 1 April to 31 December 2013 there were 47,984 ‘999’ emergency calls from Cumbria. This is an increase of 3.3% for the same period in 2012. 2.3.11 For the same time period the NWAS performance figures for Cumbria were: Red 1 - 67.2% National Target - 75% Red 2 - 72.1% National Target - 75% A19 - 89.6% National Target - 95% 2.3.12 None of the categories achieved the national targets, although NWAS explained that there were only 4 - 5 R1 incidents per day and this skews the figures. They went on to say that the R1 figure is comparable to other rural areas. There are 53 - 55 R2 incidents per day in Cumbria. Focus is increasing on quality outcomes for patients and may in the future change the reporting structure of ambulance services. 2.3.13 Calls are categorised upon the information that the caller gives. When a call is received by the Emergency Medical Dispatcher (EMD) software is used to ask a set of questions to ascertain the patient’s condition. This will enable the call to be categorised correctly and a vehicle, if required, to be dispatched. 2.3.14 EMD’s are not clinically trained but have experience and expertise in talking to people. The EMD has trained nurses and paramedics on hand to assist with the call and the categorisation can be changed if the patient’s condition deteriorates or improves.

2.3.15 Community First Responders (CFR)

2.3.16 Community First Responders are groups of volunteers who live and work in the local community. 2.3.17 The volunteers are trained by NWAS to attend certain emergency calls where time can make the difference between life and death. The responder provides care until the ambulance arrives. 2.3.18 The ambulance service controller send the CFR’s to Category R1 calls (immediately life threatening). They are dispatched at the same time as the ambulance crews but because they are located in areas closer to the caller, can often arrive more quickly than the ambulance. 2.3.19 Often the role the CFR’s play is one of reassurance. In some instances where someone is having chest pains, simply giving them oxygen can make a big difference. In extreme cases the First Responders are trained to perform CPR (cardio pulmonary resuscitation) or use a defibrillator to restart someone’s heart. 2.3.20 Each volunteer carries basic First Aid equipment and a simple to use Automated External Defibrillator (AED). 2.3.21 NWAS has 749 active Community First Responders in the county, working in 73 teams. The Trust has expressed their gratitude for the time the volunteers put in to help their communities and continues to actively promote the teams and recruit new members.

2.4 Background to the Ambulance Service in Eden District

2.4.1 The district has two ambulance stations - Brough and Penrith. There is also an Alston Ambulance that whilst affiliated to NWAS is run by volunteers (see below). 2.4.2 The Brough station has one ambulance that works 16 hours Monday to Thursday and 24 hours Friday to Sunday. 2.4.3 Penrith station has one 24/7 ambulance and one 24/7 Rapid Response Vehicle that is usually manned by the Ambulance Operations Manager who is a paramedic. 2.4.4 The ideal ambulance team would be a paramedic and an Emergency Medical Technician (EMT) but this is not always the case as there is a shortage of paramedics in the county. Currently there are 19 paramedic vacancies in the county. 2.4.5 On the data available at the time of writing the report (to January 2014), NWAS in Cumbria responded to 66.88% of Red 1 calls and 72.66% of Red 2 calls. 2.4.6 These were the lowest response times in the region. 2.4.7 There are 21 Community First Responder groups in Eden district. 2.4.8 Community First Responders are volunteers who attend emergencies when requested. The Lead CFR is given equipment to attend emergencies but the other volunteers have to pay or raise funds to cover the costs of additional equipment. 2.4.9 NWAS supports Heartstart training by encouraging CFRs to provide courses for their communities. Many of the schemes are open to the public and all are free. 2.4.10 Many of the rural communities in Eden have a publically accessible AED available in their village or parish. There are some AED’s available for public use in the key service centres in the district but do not appear to be well advertised. 2.4.11 Alston Ambulance Service

2.4.12 The Alston Agency was set up in 1952 when County Council contracted a local garage to service and drive the local ambulance. The agreement subsequently transferred to NWAS. 2.4.13 The Alston Agency was paid an annual sum to provide a first response service for the community. This service has been very successful however, it desperately needed to be modernised to CQC standards. 2.4.14 No changes have taken place to the emergency ambulance provision provided by NWAS; but it was recognised that response times do not meet national targets. The nearest NWAS ambulance station is located in Penrith which is 40 minutes’ drive in good weather conditions.

2.5 Background to Eden District

2.5.1 The story of health and wellbeing in Eden is a positive one. 2.5.2 The district has high levels of educational attainment, low levels of unemployment and a strong sense of neighbourhood belonging. 2.5.3 People living in Eden tend to make positive lifestyle choices. Levels of smoking, alcohol related harm and drug misuse are low, while the numbers who eat healthily and participate in sport are high. However, Eden has the second highest level of childhood obesity in Cumbria. 2.5.4 The impact of major diseases on the residents of Eden is comparatively low. 2.5.5 While Eden performs strongly across a range of health and wellbeing indicators, high performance overall conceals significant inequalities in health outcomes within the district. Eden has the highest life expectancy in Cumbria yet there is also a 14.6 year gap between the wards with highest and lowest life expectancies.

2.5.1 Alston Moor

2.5.2 Alston Moor is in the east of the district, bordering with Northumberland. Alston Moor has a population of 2400 spread over approximately 200 square miles. Due to its height above sea level and surrounding hills, Alston frequently suffers from low cloud and high snowfall. These conditions make access extremely difficult by road and air on many occasions during the year. The local District General Hospital in is 30 miles away with a minimum drive time under emergency conditions in good weather of 45 minutes. 2.5.3 According to HMG National Indices of Deprivation Alston Moor is the most deprived area for geographical barriers and is also referred to as the most remote sizeable rural community in mainland .

2.6 Automated External Defibrillators

2.7 CFRs carry a medical kit including an AED. CFRs also undergo initial training and ongoing training for their volunteer work. 2.8 Many villages in Eden now have publically accessible AEDs and residents have had Heartstart training where part of the training is a familiarisation with the machines. 2.9 Publically accessible AEDs are increasing in number.

3. Methodology

3.1 Desktop Research

3.1.1 NWAS has a website that has a lot of information that was used in the review. The website had statistical information, newsletters and public information; all of which was helpful to the review. (See Bibliography at the end of the report for links) 3.1.2 Minutes and reports of the Cumbria County Council Health Scrutiny Committee were read and used for background information. 3.1.3 Other internet websites were used to assist with research and background information such as:  NHS England  Healthwatch  Centre for Public Scrutiny A full list can be found in the Bibliography at the end of the report.

3.2 Summary of Review Meetings

Meeting Witnesses Evidence Gathered Pre scoping 1 - 20.1.14 None Briefing for Review Group to give an overview of topic

Pre scoping meeting 2 - Cumbria County Council NWAS half yearly report 30.1.14 Health Scrutiny Meeting

Pre scoping meeting 3 - Public Meeting at Alston Agreement of proposals to 31.1.14 run an Alston Ambulance Service manned by volunteers and organised by NWAS

Pre scoping 4 - 13.2.14 Witness 1 Information regarding Community First Responders in the district

Scoping Meeting - 4.3.14 None Setting the Terms of Reference

Review Group Meeting - None Setting Witness Session 18.3.14 dates Meeting Witnesses Evidence Gathered Review Group Meeting - None Setting Witness Questions 25.3.14

Witness Session 1- Witness 1 - District Using the service 1.4.14 Resident Witness 2 - Employee Procedures within the service Staff morale Using Sat Nav v local knowledge

Witness 3 - Eden Using the service - Community Alarms emergency response to falls

Witness 4 - Mountain How the services link Rescue (email responses) Witness 5 - Healthwatch Patient responses of the (email responses) service

Witness Session 2 - Witness 6 - UNISON Discussion of the proposal 13.5.14 to withdraw the RRV for 5 hours per night in Penrith Staff morale Staff shifts and the European Working Hours Directive Witness 7 - Malcolm How the proposals for the Foster new Alston Ambulance Service is moving along Response times to Alston

Witness Session 3 - Witness 8 - NWAS Emergency coverage in the 29.5.14 representatives - district and county Salman Desai - Head of Response times in the Service Development district and county Sarah Smith - Assistant Joint working with the CCG Director of Corporate Using the installed sat nav Communication in vehicles Peter Mulcahy - Head of Call taking procedures Service Community First Responders Mountain Rescue Witness 9 - Alison Meeting Witnesses Evidence Gathered Clegg, Head of Joint working initiative with Performance, Cumbria NWAS Clinical Commissioning The health structure (in a Group nutshell) Witness 10 - Dr Theo Weston, BEEP Service Background to the BEEP service Current activities and how it fits with NWAS A vision of the future

3.3 Surveys

3.3.1 Survey of Ambulance Services in England

3.3.2 Tertiary information was used from a Review document written by Bassetlaw District Council who obtained information from six ambulance services across the country. The table can be found at Appendix B.

3.3.3 Survey of the local communities

3.3.4 The Group produced a poster and flyer and over 400 were issued in the district asking people to respond with their stories of the emergency ambulance response to their calls. 3.3.5 The Group received a number of responses and in almost equal parts there were good and bad reports, some of which are quoted below.

3.4 Letters

3.4.1 EDC sent a letter to the Chief Executive of NWAS following two incidents on the council premises when it had taken over 40 minutes on each occasion for an emergency ambulance to attend. 3.4.2 A response was received but it was felt that it was uninspiring as averages were quoted for call outs and they failed to acknowledge the issues in sparsely populated rural areas.

3.5 Media Releases

3.5.1 The Review Group obtained various media articles from across the country regarding the country’s ambulances services. 3.5.2 The local newspaper, The Cumberland and Westmorland Herald, also ran a number of articles during the review that assisted the research. 4. Addressing the Scope: Evidence Gathered

4.1 To review the Emergency Ambulance Service within Eden District and in the wider context of Cumbria

4.1.1 Our aims at the start of the Review were:  To consider the introduction of local maximum waiting times for rural areas for Category R1 and R2 calls  To ensure the emergency ambulance coverage is adequate  To identify suitable locations for publically accessible AED’s  To assist in the recruitment of more CFRs in the district, if needed  To use local newsletters to raise awareness of when people should and should not call 999 and what the communities can expect as a response from NWAS  To investigate whether there should be CFRs based at the Council premises during daytime hours  To ensure Heartstart training is offered to members and officers especially for use at evening meetings  To monitor the implementation of the new proposals for the Alston Ambulance Service

4.2 Emergency Ambulance Coverage in Eden District

4.2.1 Eden district has two ambulance stations, Brough and Penrith comprising of two ambulances and one Rapid Response Vehicle. The Brough ambulance covers 24 hour shifts Fridays to Sundays; the remainder coverage is for 16 hours. Penrith has a 24 hour ambulance and RRV, seven days per week. 4.2.2 When the ambulance is called away from Penrith the RRV is on standby with the Brough ambulance as cover. If both ambulances are on calls cover is provided by either or Keswick ambulances. This also applies when the Brough ambulance is not on shift for 8 hours Monday to Thursday. 4.2.3 In Eden there were 130 R1 calls received last year which is equivalent to one call every three days and a performance rate of 56.2% 4.2.4 During the same period there were 1829 R2 calls with a performance rate of 63.7%. 4.2.5 NWAS stated these were very small numbers and there are additional difficulties with geography and population density. They are working with the CCG to improve response times and identify issues. 4.2.6 Alston has its own ambulance run by volunteers and supported by NWAS due to its geographical remoteness. (See dedicated paragraphs in this report relating to Alston). 4.2.7 During this review NWAS announced that it was proposing to withdraw the RRV located in Penrith for five hours per night - 2am to 7am. 4.2.8 This proposal plus the withdrawal of one ambulance per night in Carlisle was part of a bid to save £600,000 this year in the Cumbria and Lancashire region. Across the whole region NWAS needs to save £1.4million. 4.2.9 NWAS was asked about the proposal and replied that the RRV was underutilised. During the night time the RRV has 0.2% utilisation which was deemed an ineffective use of time. NWAS is making greater use of the ‘hear and treat’ service as part of a national directive to avoid unnecessary hospital admissions. 4.2.10 The role of the RRV is to cover the area when the ambulance is called away. If the car and the ambulance are both at a call and one is required elsewhere the vehicle with the paramedic in would be sent. Currently the RRV is always manned by a paramedic. 4.2.11 Currently Cumbria has 19 paramedic vacancies. If the proposals to withdraw the night time RRV in Penrith and an ambulance in Carlisle the staff would be redeployed and a reduction in the number of vacancies would occur. 4.2.12 Penrith station has a core establishment of 8 staff. This is split between four paramedics and four technicians. This allows cover for annual leave and sickness. Extra staff is brought in for events such as Appleby Fair. On the whole the system works but there are constant pressures on staff not just in Penrith but across the region. There have been media releases recently indicating that emergency ambulance staff are battling with stress countrywide. 4.2.13 Members queried why the service was being cut if it was consistently underperforming. Given the overheads in a rural area including additional fuel and wear and tear, it was suggested that it would be more sensible to move resources or make reductions from areas which are constantly overachieving. It is a concern whether the proposed cuts were one off savings or year on year cuts. Whilst NWAS did not give a direct answer they did say that within the next few weeks they were meeting to look at cost cuts for next year. 4.2.14 Members were told that staff and the union did have alternative ideas for reducing costs which would not impact on front line services. NWAS is talking to the union and staff before the proposals are implemented. 4.3 Response Times 4.3.1 The review gathered information that showed that NWAS has achieved the national response times for A8 and A19 calls. However, this was on a regional basis only which is the standard set for Ambulance Services. They are not nationally held to account for county or district level response times that is consistently underachieved in Cumbria. Cumbria Health Scrutiny Committee does hold NWAS to account for the county aspect of the national targets. The review looked at the response time data on a divisional level and district level and it was clear that Cumbria response times were well below the target. It is clear that over performance in urban areas mitigates for poorer performance in the rural areas. See Appendix A 4.3.2 According to the National Audit Office “Rural areas present inherent challenges for an efficient, fast-responding service because calls are less frequent and widely spaced”. 4.3.3 When a 999 call is received in certain circumstances CFRs are deployed as well as an ambulance. If the CFRs responds within the eight minutes national target that contributes to the NWAS response times and the clock stops. The clock does not stop on the second 19 minutes national target for an ambulance to attend to transport the patient. 4.3.4 If another emergency R1 call comes in to the call centre the ambulance on its way to the first call may be diverted if the second call is designated a higher priority. 4.3.5 The call handling department is based in Broughton near Preston and take all calls for Cumbria and Lancashire. They also take calls from across the region if the other call centres are busy. There is also a dispatch desk and that is dedicated to Cumbria and has specific knowledge of Cumbrian geography. 4.3.6 Emergency ambulances are fitted with satellite navigation (sat navs) systems defaulting to the ‘fastest route’. The staff also has paper maps in the vehicles and most crews will have local knowledge of the area. 4.3.7 One parish council responded to the Groups’ posters informing them that in their area the sat nav takes the crews on to a road on a moor that has several gates to negotiate. The parish council said they had tried on several occasions to get NWAS to change the route but to no avail. 4.3.8 NWAS at their meeting with the Group informed them that they have an initiative called ‘Point Taken’. The initiative involves sending out cards to people whose properties are located in remote locations. The residents can complete the cards and return them to NWAS who then use grid references to pinpoint the locations on their maps and other pertinent information to ensure a faster response time. NWAS said they would be willing to readvertise this initiative in a bid to map more remote locations in the district. 4.3.9 The Group was informed via email and letter from users of the emergency service of:  The quick response (within the national target) and the calm professionalism of paramedics dealing with a small child with a life threatening illness, where both a land ambulance and an air ambulance responded. The baby responded to treatment and is home.  The kindness and care of an off duty paramedic when a resident was involved in a car accident. There was also a quick response when the emergency was called in. After a short stay in hospital the patient has now recovered.  The emergency in a rural location where a CFR was first on scene quickly followed by an off duty GP, paramedics, a land ambulance and an air ambulance. Unfortunately the patient died later in hospital.  The patient who was alone and rang for help after suffering a heart attack and who wrote their Will while waiting for an ambulance as it took some time to arrive. Despite the wait the patient recovered and is now home.  An emergency call made concerning an elderly patient who had collapsed in church. According to the caller the EMD was most “frustrating and worrying”. There was confusion regarding the location and no one knew the post code which was being asked for. Eventually the caller heard the EMD say they “had found the M6”, then the caller was able to give directions from the four directions an ambulance could come from. An ambulance arrived 25 minutes after the call was made. The location was just two miles outside of Penrith although it was not established whether the ambulance came from there. The final paragraph of the correspondence was addressed by the Group (see the Raising Awareness section): “In addition to raising questions about call centre competence it could be that the general public needs to be informed of the information routinely needed by the call centre”. 4.3.10 NWAS stated that they used different ‘pathways’ when dealing with emergency calls:  Some 999 calls are clearly life threatening or very serious and possibly life threatening where there would be an immediate dispatch of an ambulance and possibly other assistance such as a CFR or an air ambulance.  Other calls are identified as ‘Green’ and those do not have a national response target although NWAS has set their own targets.  NWAS has two further ‘pathways’ for calls. The first is ‘hear and treat’. There are trained nurses and paramedics in the call centre that can deal with some of the calls taken. They will listen to the patient’s symptoms and treat over the telephone.  The second pathway is ‘see and treat’. This ‘pathway’ is for patients who are already being assisted by other healthcare professionals such as social care etc. The healthcare professional would be contacted and requested to make a visit to assist. 4.3.11 The Group was told by a witness that they made regular emergency calls because of clients falling. The witness was less than happy at the response times of the emergency ambulances. The point put over to the Review Group was that the longer a fall patient is left the longer recovery time and it also takes a longer time to recover self-confidence. 4.3.12 Although the witness obtains a call log number from the NWAS call centre they do not appear to get any information on the coding of the call eg. Red or green, nor how long the ambulance will take to attend. 4.3.13 Whilst the Group understands the time taken to attend affects recovery time it is suspected that many of the calls will be coded green where there are response times between 30 minutes and 2 hours. Also if an ambulance is on its way and a red call comes in they could be diverted to the higher priority.

4.4 Developing a Rural Response Time Target

4.4.1 The Review Group’s terms of reference stated that it should consider if/how the non-achievement of targets could be overcome. 4.4.2 One consideration put forward by the Group was the possibility of developing a realistic but challenging local target for Categories R1 and R2 responses in rural Eden to help drive up performance. 4.4.3 Whilst gathering evidence the Review Group was told on more than one occasion that there should not be a separate rural target as this would create a ‘two-tier’ system. It was pointed out that people in rural areas pay the same amount towards the provision of ambulances as people in urban areas and therefore they should be able to expect the same level of service. 4.4.4 The Group agreed that the principle of the above was understandable and agreed with the sentiments but felt it was simply unrealistic to expect ambulances to be able to respond to calls in rural areas as quickly as they can in more densely populated areas. 4.4.5 On 16 April 2014 RSN Online (Rural Services Network) broke the news that South West Ambulance Service was to scrap the eight minute waiting time target for rural areas. The SW Ambulance Service told local doctors that they would “have to set more realistic ‘trajectories’ for hard to reach country areas”. SWAS said it was still duty-bound to make the national eight-minute target across the whole of its area, but would do so by getting to emergencies much more quickly in cities and towns. 4.4.6 One response from an MP stated that people living in rural areas were “being told to settle for second best” and it was a “cavalier approach” being taken by SWAS. 4.4.7 On 23 April 2014 it was reported on Look North (BBC local news for north Cumbria), that a call was made to the North East Ambulance Service for a patient who had collapsed with a suspected heart attack. It took an emergency ambulance two hours to attend and the patient sadly passed away before the ambulance arrived. NEAS stated there were severe resources and capacity issues and there was no ambulance available at the time of the call. 4.4.8 The suggestion from one witness stated that elongating the national targets for rural areas may actually reduce the coverage. 4.4.9 NWAS was keen to keep the national response targets as they felt that a benchmark is a good thing to aim for. They did believe that there should be more emphasis placed on patient outcomes rather than solely on response times.

4.5 Community First Responders in Eden District

4.5.1 If a CFR responds to a Category R1 call within eight minutes then this counts as a successful response for NWAS against the national target. This is seen as appropriate because for certain types of calls, particularly cardiac arrests, and a quick response by a CFR can make a significant contribution towards saving the patient’s life. Research suggests that the chance of a successful outcome following the onset of cardiac arrest reduces by 7% to 10% with each minute that passes; therefore rapid response by a CFR using an external defibrillator can greatly increase survival rates. 4.5.2 At the 15 April 2014 Eden district had 21 CFR Groups. There were no groups recorded in the key service centres with the exception of . 4.5.3 The Review Group had been told at a Witness Session that some volunteers were being trained in Penrith. 4.5.4 It was suggested by the Review Group that perhaps CFRs could have their remit extended to encompass falls. One of the witnesses said that a lot of ambulance time was taken up attending to fall patients and that it may be a good idea to extend the CFR remit but added a word of caution. People fall for many reasons and often there is an underlying cause such as a stroke, an existing ailment, or it could be a fall from excess alcohol and that could bring a potential risk to a response crew. As said previously an ambulance would be dispatched but if a higher priority call came through it could be diverted. 4.6 Alston Ambulance Agency 4.6.1 For the past two years there have been meetings and consultations regarding emergency healthcare in Alston Moor. 4.6.2 The project came about following the decision by NWAS to withdraw the Alston Ambulance provided by the Alston Agency due to safety concerns and the lack of Care Quality Registration. 4.6.3 The aim of the project was to identify how a safe, effective service for patients, offering equitable access to emergency healthcare could be achieved. 4.6.4 A consultation paper was issued in June 2013 offering four options for the future of emergency healthcare in Alston Moor. All relied on community support encompassing either trained Community First Responders (CFR’s) or Enhanced CFR’s and/or supported by an emergency community run response vehicle. 4.6.5 On 31 January 2014, just before this review was scoped; a public meeting was held in Alston where an agreement was reached between NWAS and the Alston community for the future of emergency healthcare in Alston Moor. NWAS and Cumbria CCG confirmed that they would support an ambulance on Alston Moor. They would also provide support and training for twelve volunteers, to allow them to man the vehicle. 4.6.6 The Group were told that although there is an ambulance 24/7 at St. John’s Chapel, approximately 10 miles away it falls under the North East Ambulance Service and despite trying for a number of years to get cross boundary co- operation this has been unforthcoming. 4.6.7 There are approximately four incidents per week requiring an ambulance on Alston Moor, which equates to approximately 208 - 220 per annum. 4.6.8 The Air Ambulance only flies in daylight hours cannot fly in low cloud cover and cannot always land near an accident necessitating the need for a conveying vehicle. Sometimes the air ambulance has had to wait for an ambulance to convey the casualty. The air ambulance is called out approximately 20 times per year. Call outs are heavily skewed to the latter months of the year. 4.6.9 Anecdotally CHOCDoc (out of hours GP service in the county) rarely attend patients on Alston Moor so they either had to drive/be driven to an open healthcare centre or call an ambulance. 4.6.10 There are a number of CFRs in the communities who provide excellent support but they are only trained to basic level. They are unable to convey, move or handle patients nor are they able to deal with children under the age of 12. Guidance from the Department of Health suggests that CFRs should not be in charge of a scene for more than 20 minutes. 4.6.11 The current position in Alston Moor is that NWAS and the CCG have agreed to provide a fully equipped ambulance that will be staffed by 12 volunteers trained to EMT level. This will enable patients to be conveyed and moved, assist trauma patients and children. It is hoped that maternity patients will be covered too. 4.6.12 The selected volunteers will have to undergo a 6 week training programme that will be individually tailored to meet their other responsibilities. It is hoped that the remaining volunteers who are not selected will be given the opportunity to train as CFRs. 4.6.13 All the training will be done under the auspices of NWAS who is providing insurance cover. 4.6.14 The Group were told that Rory Stewart MP had been very helpful and had set up a meeting with the Health Minister who had been very positive and helpful as had the Medical Director of the National Health Service for England. 4.6.15 The witness expressed sympathy for the ambulance service which was being used to plug gaps not of their making. He stated “that if GP practices were not open people were going to ring [the emergency ambulance service]” He felt that the use of minor injury clinics should be investigated and that there should be more publicity for the CHOCDoc service and how it operates.

4.7 Automated External Defibrillator (AED) Towns

4.7.1 Public Access Defibrillators

4.7.2 When a person suffers a cardiac arrest, they lose consciousness immediately and there is no sign of life. An AED delivers an electric pulse through the chest, in an attempt to restore normal heart rhythm. A patient’s chance of survival decreases 7 - 10% every minute that passes without defibrillation. The best possible chance of survival is maintained when the application of the AED is within five minutes of collapse. 4.7.3 Heartstart training is supported by NWAS who encourage CFRs to provide courses for their communities. Many schemes are open to the general public and all are free. Courses last for 2 hours and provide very practical ‘hands-on’ learning. 4.7.4 Young people of ten years and over can attend Heartstart training although other skills such as making 999 calls or the recovery position can be taught to much younger children. 4.7.5 Eden District Council has now purchased several AEDs. There are AEDs located in the Town Hall, Mansion House, Penrith TIC/Museum, Frenchfield Sports Centre and the Cemetery office that are publically accessible when the buildings are open to the public. The Democratic Services office also has a second AED which officers take to offsite meetings and the Leisure/Communities Team can borrow various AEDs for major events such as the Penrith Triathlon or other community events where first aid is provided. 4.7.6 There are also a number of officers who have attended Heartstart training. 4.7.7 Asked about creating ‘AED Towns’ many of the witness said that knowledge was a good thing. Increasing the number of publically accessible AED’s and increasing the numbers taking up training could only be a good thing. 4.7.8 Chain of Survival 4.7.9 The Chain of Survival initiative focuses on four key immediate actions, which when delivered in sequence will give the patient a greater chance of survival; these are:  Early access - call 999  Early CPR  Early defibrillation  Early advanced care 4.7.10 Access to an AED and a trained user means that three of these lifesaving actions can be administered, possibly before the ambulance arrives. 4.7.11 Public access for AED’s and public knowledge of the location of the machines could quite literally be the difference between life and death. 4.7.12 During the evidence gathering part of the review County Councillor Libby Bateman informed the Chairman of the Group that there is a mobile phone ‘app’ that can show the user where there is a publically accessible defibrillator in the area they are located should the need arise to use one. South Central Ambulance Service has created this ‘app’ and Councillor Bateman has offered her support for the app to be rolled out nationally. 4.7.13 “AED’s Saves Lives”. The Resuscitation Council (UK) strongly recommends the implementation of early defibrillation. Increased provision of early defibrillation through the widespread deployment of AED’s is now considered a realistic strategy for reducing mortality from cardiac arrest”. (The Resuscitation Council (UK))

4.8 Raising Awareness

4.8.1 The Group felt that NWAS was not using local publicity networks to inform the public about changes to the emergency ambulance service they provide such as the use of CFR’s, Rapid Response Vehicles, ‘hear and treat’ or other healthcare pathways. 4.8.2 Whilst undertaking desktop research the Group read a scrutiny review undertaken by the Health and Overview Scrutiny Committee of Gloucestershire County Council. Although the review was undertaken in 2009, so somewhat dated, the Group did feel that the suggestion put forward by Cotswolds District Council was one worth pursuing. The suggestion was that local publicity such as village newsletter should be used to reinforce the messages that can be found on the NWAS website such as “what people can expect from the emergency services”, “what the emergency services expect of the caller” and when to use the 111 telephone number. 4.8.3 Below is an extract taken from the NWAS website concerning awareness: “A large percentage of patients who call for an ambulance can be dealt with more effectively in their local community by their GP, NHS Direct or an Out of Hours Service. Please think before you call an ambulance and remember you should only call in a real emergency…”

4.9 BEEP Fund/Doctors

4.9.1 The original concept was started in Penrith nearly 20years ago and was based on an existing scheme which provided doctors with basic kit to attend roadside incidents. 4.9.2 Later a charity fund was established which allowed the purchase of a dedicated vehicle. The vehicle is equipped with specialised equipment and provides a back up to paramedics at the roadside. 4.9.3 The borders of the service vary with around a 15 mile radius but it can cover as far as Kirkby Stephen and Brough. There is an interactive pager system within ambulances which will page the BEEP service within a 25 mile radius of an incident. 4.9.4 The BEEP service, which is local to the Eden area, but also covers major incidents in the county such as the Grayriggs train crash, is now linked to a national body entitled BASICS (British Association for Immediate Care), who governs the work they do. 4.9.5 The service is voluntary; all volunteers are GP’s through the day and it receives no government funding. There are now seven volunteer doctors who are based through the day in Penrith, Carlisle, Appleby and Caldbeck. 4.9.6 The first 10 - 20 minutes in a road traffic accident are critical and the volunteer doctors can and have provided medical interventions that paramedics are not able to carry out. 4.9.7 Although a voluntary scheme the service does have ‘blue light’ status and the volunteers undertake driver training with the Lancashire Police Authority. 4.9.8 A Memorandum of Understanding is being developed between BASICS and the ambulance service for a formal relationship that will also include supply of disposable equipment. 4.9.9 There are still some issues with the ambulance service not calling out the BEEP service although reasons for this have not been established. The Group had also been informed that this had happened with the air ambulance and Mountain Rescue. 4.9.10 NWAS is looking at an initiative where they employ doctors for attending emergencies. The initiative is entitled MERIT. Dr Weston, originator of the BEEP Fund service, was one of the first tranche of doctors from the North West to undertake one week of training to be able to be part of the scheme. NWAS is hoping to train 75 doctors for the North West region. 4.9.11 Asked what the ideal would, be in the witness’s opinion, the Group was told better integration between the BEEP service and the ambulance service, to be a formal part of the ambulance service and ideally to be paid but this is not the norm so to be taken on board in a more structured manner. 4.9.12 The Group was told that if the BEEP service was called out 1in 5 cases the service arrive before the ambulance service and in 1 in 10 cases no ambulance is required after a doctor’s attendance at the scene.

5. Conclusions

5.1 Emergency Vehicle Coverage in Eden District

5.1.2 Eden has two ambulance stations in the district with two ambulances and a Rapid Response Vehicle. During the review NWAS announced a proposal to withdraw the RRV from Penrith for five hours per night stating it was only used 0.2% of the time which is equivalent to a call out every three days. 5.1.3 Members felt that if NWAS was not making the national targets in the district or the county cutting front line services was not the way to proceed even if the Trust needed to save £600,000 in the Cumbria and Lancashire area. 5.1.4 The Housing and Communities Committee and the Leader of the Council were informed of this proposal and it was agreed that the Leader would send a letter of objection to NWAS stating the reasons why the council objected to the proposals. 5.1.5 The Review Group considered that the district could ill afford any reduction in coverage because if the Penrith ambulance is out on a call the RRV is used as standby. On occasion both the ambulance and RRV are called out to the same incident and the Brough ambulance will be moved to cover the entire district. The Brough ambulance does not cover night times Monday to Thursday which means if the Penrith ambulance is out either the Sedbergh or Keswick ambulances are moved to cover. The ambulance crews are being asked to cover a very large area should an emergency arise. This will be exacerbated as the proposal to withdraw the RRV also included the total withdrawal of one ambulance at night in Carlisle.

5.2 National Response Targets

5.2.1 All Ambulance Trust performance is assessed as an aggregated percentage of calls across the area covered by the Trust. This nationally determined method of reporting performance means that information about local variations in response times is not routinely reported or assessed. 5.2.2 Data obtained by the Review Group clearly demonstrates that performance in high call volume (generally urban) areas is better than in low volume (generally rural) areas. Performance in Cumbria is consistently below the national targets but this is masked by the targets being met in Greater Manchester and Merseyside. 5.2.3 The current emphasis on the delivery of the national response times is contributing significantly to the creation of a ‘two tier’ ambulance service that disadvantages people living in rural areas. 5.2.4 The Review Group is convinced that there are some major failings in relation to the measurement of national targets and that this issue needs to be addressed urgently by the Secretary of State for Health. 5.2.5 The Group concluded that developing a rural response time target was not the answer as it would only create more perceptions of a “two tier system” which is not the outcome the Group was aiming for.

5.3 Community First Responders

5.3.1 Community First Responders attending to a Category R1 or R2 call is a complement and not an alternative to an ambulance, but by arriving on the scene the community first responders ‘stop the clock’ in terms of the recorded response times. The extent to which this gives a misleading indication of ambulance response times is not clear. 5.3.2 The Group concluded that NWAS should provide clear and concise information about the role, responsibility and contribution of Community First Responders to improving patient outcomes. 5.3.3 Community First Responders have to raise funds to enable them to purchase equipment. The Group felt that CFR’s should be treated equally with Mountain Rescue. Mountain Rescue does not pay VAT on medical supplies and equipment (including vehicles if they are classed as ambulances). The national Government grants the Mountain Rescue around £200,000 per year which is intended as some sort of compensation for the VAT paid on other items and services. In Mountain Rescue terms this averages approximately £2,000 per team. 5.3.4 CFRs are to have their pagers upgraded to the same equipment the ambulance crews have. These are radio pagers entitled ‘Airwaves’ that have stronger signals so still work in more remote rural areas. 5.3.5 From an NWAS perspective, the advantage of Airwave pagers is that they show the position of the pager on the mapping system in the control room. This means they can see if they have anyone near an incident and dispatch them more efficiently. 5.3.6 The disadvantages from a CFR perspective are that NWAS are only providing one pager per group free and are expecting the groups to either pay for more or pass the one around between them. This would also mean that only one CFR would be tasked to an incident whereas at the moment the whole group gets the message and typically two or three attend the incident. With only one CFR in attendance there will be considerably more pressure on that individual. It is a lot to ask of volunteers with relatively little training or experience. NWAS would only send experienced paramedics out alone in a car to an incident. New paramedics would always be on a double crewed ambulance to treat, deal with relatives, phone NWAS, and in rural areas, go out to the main road to direct the ambulance in. 5.3.7 The Group was told that the CFRs would have to pay for the licenses but were again given conflicting information regarding how much the annual licenses would cost. CFRs are volunteers who are an important part of the emergency ambulance service especially in rural areas and it was felt there should be some assistance from NWAS towards all these necessary costs. 5.3.8 The Group agreed that CFRs responding to certain types of falls should be investigated further. If even a small percentage of fall patients were transferred to CFRs it would release some of the burden from the emergency ambulance service and could contribute to a faster recovery time for the patient. 5.4 Automated External Defibrillators (AED’s) 5.4.1 Many of the parishes and villages in Eden are purchasing publically accessible AED’s and residents are undertaking Heartstart training and are therefore in the process of assisting NWAS by ‘helping themselves’ and those that may require emergency care. 5.4.2 The key service centres in the district are beginning to look to purchasing AED’s for public use but there is still work to be done. The Group concluded that making the key service centres AED Towns with Heartstart training for a wide range of residents such as school pupils, community groups, business people etc. would be a ‘help yourself’ solution for emergencies in the larger towns in the district. 5.4.3 The Group concluded that the phone ‘app’ was a good initiative and felt that Councillor Bateman should be supported in her bid to have the app rolled out nationally.

5.5 Raising Awareness

5.5.1 With reference to the NWAS website and their request for people to find alternative ways to be treated unless it is a real emergency, chest or abdominal pain etc. The Group agreed that it is an aging population in this district, with many residents unable or unwilling to access the internet and the message from NWAS needs to be to be publicised in other formats to ensure being read by as many people as possible. 5.5.2 There is too much focus on targets and not sufficient focus on outcomes. There needs to be a holistic approach. The BASICS service is working with the air ambulance to gather data to score outcomes and assess whether the right care was given to the patient. This looks as though it could be a good transferrable idea.

5.6 Alston Moor

5.6.1 According to the information the Review Group received the initiative in Alston is moving along. There have been a number of volunteers to take up the advanced training and it is hoped that those who are not chosen for the advanced training will be trained as CFRs. 5.6.2 The Group had heard about the vision for future healthcare in Alston Moor with the hope that tele-visual treatment could be implemented using cameras in the ambulance connected to major trauma hospitals and hope that their visions will be realised. The Group would support this progression.

5.7 The Scrutiny Review in the Wider Context

5.7.1 Although this review was to look at the emergency coverage and response times in Eden the Group has had to look at the wider context to put some of the problems into context. 5.7.2 Rural response times across all the ambulance services are not meeting the national targets. Some the ambulance services, including NWAS, are publishing figures that show the national targets are being met. This is because the figures published are for the region and fast response times in urban areas are masking the failure in the rural areas. 5.7.3 It is concluded that this is a national problem therefore it should be pointed out to the Secretary of State for Health. 5.7.4 The changes to the National Health Service (NHS) appears to be more complicated than before with all the different strands for commissioning different services and who does what. 5.7.5 The ‘Centres for Excellence’ initiative takes ambulances out of the county as the hospitals are mainly located in the north east. 5.7.6 Taking patients to Accident and Emergency in Carlisle can and does hold up ambulances that sometimes have to queue to hand over their patient. The ambulance then has to be cleaned and resupplied before being available for service again. 5.7.7 More use needs to be made of minor injury clinics rather than taking all patients who need to be transported to A&E’s. 5.7.8 Moving to the CHOC service has placed an additional burden on ambulances as it is not responsive enough. The Group heard from several sources that:  The out of hours services undertake the ‘hear and treat’ care pathway as a primary response to calls  The Group has been told anecdotally that CHOC Docs do not attend patients living in the Alston Moor area and on occasion callers from across the district have been told to ring the ambulance service directly.  One witness expressed sympathy for the ambulance service stating that if GP practices were not open people would phone the ambulance service or turn up at A&E’s. 5.7.9 There should be a holistic approach to commissioning services to ensure there is not an overburden on any one service. 5.7.10 Please Note: Withdrawal of the RRV for 5 hours per night in Penrith Following the completion of this report it was announced in The Evening News and Star on Monday 16 June 2014 that the proposals to withdraw the RRV in Penrith and the cut to ambulance cover in Carlisle had been put on hold by NWAS. The RRV had already been withdrawn from 5 hours of night time service but according to the union convener it would be re-instated from week commencing 16 June 2014. NWAS has put the proposals on hold until they have engaged properly with the GP-led clinical commissioning groups, although NWAS representatives had attended a meeting where the strength of feeling of the public had been heard. NWAS, at the time of publication in the newspaper, had yet to confirm they had put the proposals on hold. The Group has been informed that the RRV will remain for one year as some extra funding has been given to NWAS. 5.7.11 Care Quality Commission Inspection Following the finalisation of this report the Group was informed that the CQC was to inspect NWAS on quality and safety. Representatives of the Group attended a meeting at CREA in Penrith on 23 June 2014 for the CQC to hear evidence about the quality and safety of services before the inspection in July. There was a very good attendance at the session including CFR’s, Mountain Rescue, Air ambulance and a number of district councils and the county council. Unfortunately the CQC inspector did not attend due to a miscommunication. The CQC are focussing on emergency services and patient transport and had five questions? 1. Are services caring? 2. Are services safe? 3. Are services effective? 4. Are services responsive? 5. Are services well-led? It was agreed at the meeting that when looking at the front line services and the ambulance crews the answers to the questions were very positive as the ambulance staff work very hard, are caring and very professional. The session attendees agreed that the CQC needed to look at the NWAS structure rather than the front line services where they would find very different answers to their questions. Due to the CQC Inspector’s non-attendance the inspection has been put back until mid-August to allow time for the feedback to be sent to them.

6. Recommendations

6.1.1 It is recommended that: 6.1.2 Rory Stewart MP be contacted and requested to forward the council’s concerns regarding the consistent failure to meet national target times in rural areas to the Department of Health. The failure to achieve the national targets in rural areas is a national problem and should be investigated by the Government. 6.1.3 The Penrith and the Borders MP to also forward the following three recommendations. National reporting for emergency ambulance call outs should have more emphasis placed on outcomes for the patient rather than response times. 6.1.4 A holistic approach is needed for healthcare. There are pressures beyond the control of NWAS such as queuing at A&E departments and problems with the Out of Hours GP service. Not all transported patients need to be taken to A&E and more use of minor injury clinics/local hospitals should be considered. 6.1.4 Community First Responders are a key part of the Ambulance Service in Cumbria and especially in Eden district and should be treated in a similar fashion to the Mountain Rescue Service in terms of VAT exemption/compensation. 6.1.5 NWAS should report the contribution made by CFR’s to their national response targets and the contribution they make to patient outcomes. CFR’s are volunteers but make a significant contribution to NWAS targets in rural areas and should be recognised for their input. 6.1.6 NWAS should consider a limited extension of the CFR’s remit to include attending fall patients that are low risk to the responder. 6.1.7 The NWAS ‘Point Taken’ initiative be re-advertised to enable more remote rural residents to register their details to assist with a swift response in an emergency. NWAS should also consider offering alternatives to their electronic version of Point Taken as Eden is an aging population where computer use is not widespread and broadband is not universally accessible. 6.1.8 Eden District Council to organise the use of parish/community newsletters to advertise what NWAS expects from a caller in an emergency and what patients/callers can expect from NWAS. 6.1.9 Eden District Council to promote the key service centres in Eden as ‘AED Towns’ with public access to at least one AED. Also Heartstart training to be promoted and offered to as many residents as possible including school pupils and businesses. 6.1.10 The County Council Health Scrutiny Panel and Eden District Council’s Health Scrutiny representative to continue to monitor the RRV situation and consider a course of action should the proposals be brought up again next year. 6.1.11 That the County Council Health Scrutiny Panel and the Eden District Council Housing and Communities Committee via the Health Scrutiny representative support County Councillor Libby Bateman in her bid to have the mobile ‘app’ for public AED locations to be ‘rolled out’ nationally.