Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon Health, Social Care and Sport Committee HSCS(5)-06-20 Papur 1 / Paper 1 National Assembly for Wales Health, Social Care and Sport Committee General Scrutiny Session: Welsh Ambulance Services NHS Trust: 12 February 2020 Introduction 1. The Welsh Ambulance Services NHS Trust welcomes the opportunity to provide evidence to Committee as part of its general scrutiny sessions with NHS Trusts and health boards. 2. This briefing paper will provide members with an organisational profile, as well as an outline of the breadth of the work of the ambulance service and recent performance pressures by way of background. 3. In addition, Committee has specifically asked for detail on: The challenges and issues faced by the Welsh Ambulance Service How the organisation’s IMTP is making an active contribution to the delivery of A Healthier Wales Waiting times, call management procedures and categorisation of calls 4. This document will provide brief detail on the matters outlined above and colleagues look forward to elaborating on these issues at the forthcoming scrutiny session. Organisational Profile 5. In recent years, the ambulance service has changed significantly, moving from what was predominantly a transport service to one which now provides clinical care and clinically focused transport services to some three million people across Wales, an area of almost 8,000 square miles, spread across a diverse and challenging urban, coastal and rural landscape. 6. In 2018/19, we employed more than 3,000 people, operating from 113 buildings, with 715 vehicles in our fleet. 7. Our services span three main areas – unscheduled, emergency care; planned non- emergency clinical transport and telephone and online advice and triage. 8. Our unscheduled care services (emergency and urgent care) provide support to patients with illnesses that are immediately life-threatening through to minor injuries. We are increasingly providing services and pathways to keep patients out of hospital, treating them at home or on scene where it is clinically appropriate to do so. 9. Each year, our Non-Emergency Patient Transport Service (NEPTS) supports hundreds of thousands of patients with a clinical need for transport to get to their hospital and medical appointments and home again, including for life sustaining services like renal dialysis and cancer treatment. 10. NHS Direct Wales (NHSDW) provides telephone and online advice to patients who feel unwell, helping to signpost patients to, or arrange, the most appropriate care for them. 11. The 111 service, which we host on behalf of NHS Wales and which was introduced from 2016, is being rolled out across Wales and provides the basis for a more integrated model of future health and care provision. A Commissioned Service 12. Ambulance services in Wales are commissioned on a collaborative basis by the seven health boards through the Emergency Ambulance Services Committee (EASC) and the Chief Ambulance Services Commissioner (CASC). Both emergency and non- emergency ambulance services are commissioned in this way. 13. The Commissioning Quality & Delivery Frameworks for Emergency Medical Services and Non-Emergency Patient Transport Services (CQDFs) set out what is expected of us by our commissioners and focus on how we can make real improvements for our patients. Both are based on a five step model of service delivery, which breaks down the patient journey by need. Visual representations of the five step models are shown below: Figure 1: Five-Step EMS Ambulance Care Pathway Designed with permission using the CAREMORE® 5 steps. Copyright, 2017 Welsh Ambulance Service Trust. Figure 2: Five-STEP NEPTS Care Pathway Designed with permission using the CAREMORE® 5 steps. Copyright, 2017 Welsh Ambulance Service Trust. 14. Each year, we agree commissioning intentions with our commissioners and the delivery of these is central to our work. 3 Demand Profile 15. The data below highlights the level of activity in terms of Welsh Ambulance services in 2018/19. 534,970 999 calls were answered by our staff at our Clinical Contact Centres (CCCs). That is slightly down on the previous year’s figure of 540,891 These translated into 465,552 verified incidents (we often receive more than one call about the same incident) 246,788 of those emergency patients were conveyed to hospital Our Non-Emergency Patient Transport Service (NEPTS) made 787,931 patient journeys during the year, which was slightly up on the previous year’s figure of 787,666 243,840 calls were made to NHS Direct Wales (NHSDW) and 3,696,770 visits were made to the NHSDW website. Both these figures were down on the previous year 276,580 calls were made to 111 service, which brings together the services of NHS Direct Wales and the GP out-of-hours service in Swansea, Bridgend, Neath Port Talbot, Carmarthenshire, Pembrokeshire, Ceredigion and Powys. This is an increase on the previous year and reflects the commensurate decrease in calls to NHSDW 16. However, during 2019/20 we have seen the pattern of demand for services continue to change, particularly in respect of Red demand, which has shown a significant increase. 17. This, together with a range of other factors, has led to a deterioration in response times, with a commensurate impact on patient safety. These issues, and the ambulance service’s response to them, are outlined in more detail later in this document. The Clinical Model 18. Committee has asked specifically for information on the clinical model used by the Welsh Ambulance Service and the way in which calls are categorised. 19. In October 2015, a revised clinical model was introduced, which focused on prioritising those patients whose condition was immediately life-threatening. Following a pilot period and independent review, the model was confirmed as permanent in early 2017. 20. At the heart of the model is a focus on quality and clinical outcome as key indicators, using time targets for those conditions where time has a significant impact on patient outcome. Calls where the patient is in imminent danger of death, for example as a result of cardiac or respiratory arrest, are categorised as RED calls and have an eight minute response target in 65% of cases across Wales. 21. The basis of the clinical model is detailed in the table below. 4 Figure 3: Clinical Response Model 22. The clinical response model is regularly reviewed for appropriateness and effectiveness. 23. In terms of the categorisation of calls, the Welsh Ambulance Services uses the internationally recognised and globally used Medical Priority Dispatch System (MPDS). 24. This is a unified system used to dispatch appropriate aid to medical emergencies including systematised caller questioning and pre-arrival instructions. 25. MPDS involves caller being asked a set of standard key questions. These questions allow the call handler to categorise the call by chief complaint which sets a priority relating to the severity of the patient's condition, i.e. red, amber or green. 26. In 2019, the Trust’s Medical Director reviewed and compared the placement of MPDS determinants by category with that of NHS England’s recently introduced Ambulance Response Programme (ARP). This work found minimal variation with England in terms of categorisation. 5 27. The Trust has Centre of Excellence’ status from the International Academy of Emergency Dispatch for all three of its 999 Clinical Contact Centres. 28. This award is recognition of the high standards of use of the Medical Priority Dispatch System (MPDS) by the Trust’s call handlers and all colleagues in the CCC who receive, process and dispatch help to our patients. 29. There are more than 3,000 emergency medical dispatch centres using MPDS worldwide, managing around 65 million incidents per year. Only 250 have achieved accreditation as a Centre of Excellence Performance over the last 12 months 30. It has been a challenging year across the health system in Wales and, regrettably, it has meant that we have not always been able to deliver the quality and timeliness of emergency response services that we would want and the public should expect. 31. For the first time since the introduction of the new clinical response model in October 2015, our Red response has fallen below the 65% target and our response to Amber patients is longer than it should be. 32. The reasons for this are complex and multi-faceted and require targeted and immediate action to address these issues in real time. 33. We also continue to work in close collaboration with our health board and other partners to tackle the system-wide issues facing NHS Wales by embracing opportunities to deliver large scale transformational change quickly. 34. It is crucial that we deliver immediate and sustainable improvements not only for our patients, but also for the people who work and volunteer for us. 35. In respect of demand, there has been both a trend of rising volume and acuity, as demonstrated in the tables below: 6 Figure 4: Total Verified Demand by Category 36. Figure 4 demonstrates that demand is growing in acuity (Red and Amber demand), and is fairly static in the lower acuity category (Green). This is in line with that is being reported by health boards in terms of the acuity of patients they are seeing via their emergency departments. 37. Figure 5 demonstrates the increase in Red demand profile, with Red demand increasing over the year from approximately five per cent of call volume, to some seven per cent of call volume. 7 Figure 5: Proportion of Total Verified Incidents by MPDS Priority – RED, AMBER1, AMBER2, GREEN2, GREEN3 38. Some of this increase is accounted for by an update to call handling practices in the summer of 2019 as part of the continual review of the clinical response model to ensure the appropriate categorisation of calls.