The Association of Ambulance Chief Executives (AACE) recognises the valuable role played by QualityWatch (QW) and has read this year’s Annual Statement with interest. The statement has rightly highlighted the improvements demonstrated in the care provided by ambulance services despite the unique challenges they face as a sector, alongside the increasing pressures across the whole health and social care system.
Demand on services has indeed accelerated, for the ambulance sector especially, at unprecedented rates over the last three to four years. NHS England’s Five Year Forward View (FYFV) and the Urgent & Emergency Care Review (UECR), aim to reshape the way care is delivered across the system to better meet this increasing level of demand. Ambulance services have a key role to play in this transformation and are committed to enhancing the models of care they provide so that patients continue to receive the highest level of care in the most appropriate setting for their needs.
As shown in the data reported in the QW Statement, responses to 999 calls categorised as requiring a fast response - i.e. Red 1 and Red 2 - are not meeting the target of 75% to be reached within 8 minutes. The focus from regulators and commissioners on this measure as a means of assessing overall performance however, leads to inefficient and inappropriate use of precious ambulance resources, which are often unnecessarily dispatched simply to try and meet time targets. The majority of these calls do not in fact require nor benefit clinically from an 8 minute response, and so AACE has been working over the past year with NHS England on an Ambulance Response Programme, to introduce changes that will ensure prioritisation is more appropriately based on clinical need. This will enable the most life threatened, emergency calls to receive the most rapid response and free up other resources to provide the optimum response for urgent and non-urgent cases.
The QW Statement refers to some of the other factors that impact on ambulance services' ability to respond to the level of demand:
i) Insufficient capacity to meet the rate of increase in demand – most trusts are reporting a need for an additional 400 paramedics on top of vacancies if they are to meet demand in their region
ii) Increasing job cycle times – this can be due to paramedics providing more definitive care on scene, or due to reconfiguration of services in the region leading to longer journey times to the most appropriate destination
iii) Delays in transfer of care at hospital Emergency Departments (EDs) – this is a most pressing factor that needs addressing across the system.
Contrary to the QW Statement, delays in transfer of care at EDs are happening all year round, not just during the winter months. In 2015/16 the number of patients waiting longer than 2 hours in ED for ambulance clinicians to be able to transfer care to hospital staff has tripled since 2013/14. The number of ambulance hours lost due to hospital handovers taking longer than 30 minutes has increased over the same period by 52%, to just under 500,000 hours.
Based on average call cycle times, this would amount to around 400,000 patients who could have received an ambulance response during those delays. This drain on ambulance resources is placing patients waiting for an ambulance response at significant risk in the community. Clearly delays in transferring patients at hospital are a symptom of system-wide pressures, with rising demand on all sectors of the health service as well as on social care services, and ambulance trusts have been working closely with their partner hospitals to try and alleviate the situation, to no avail in most locations. AACE has expressed concern that the risk to patients is not being sufficiently recognised and has called on NHS England and commissioning bodies to work proactively with providers to improve patient flow and reduce these risks by freeing up ambulances expediently to attend to patients waiting in the community.
The focus for ambulance services within the FYFV and UECR is in transforming the way their services are delivered, and the QW Statement picks up on the changing models of care they provide. As well as giving more clinical advice over the phone and either discharging or referring patients to appropriate sources of care within the community, ambulance services are increasingly providing mobile treatment services and avoiding unnecessary conveyance to hospital. ‘Hear & Treat’ and ‘See & Treat’ models reflect the broad range of clinical skills that are now expected from ambulance personnel, and that are enabling patients to receive the right kind of care, in the right location more often. To absorb the increasing demands and complexities of population health needs at the necessary scale and pace to make a sustainable difference, means that ambulance services need to be supported, through real term investment from their commissioners - to change their operating models, develop their workforce and embed new technologies and the clinical responses that will allow this transformation.
Easing pressure on hospitals
Such investment in ambulance services will lead to increasing numbers of patients being treated outside of the hospital environment, with improved and timely access to alternative care pathways and packages from primary, community, social and voluntary services where these are more appropriate for their needs. Not only would this bring further improvements in patient care, experience and outcomes, it would also ease the pressures on hospitals and realise savings across the whole system. Much of this is dependent on having relevant out-of-hospital care services available 24/7, and these need investment too.
It was hoped that these developments would be at the centre of Sustainability and Transformation Plans, but so far there is minimal evidence of this and a distinct lack of funding shift towards ambulance services from the savings made in the acute sector through increasing out of hospital treatment and referrals, and the reduction in inappropriate conveyance to hospital.
Conflicting priorities and expectations at national, regional and local levels make progress frustratingly slow. These pressures are taking their toll on staff at all levels, as well as increasing risks for patients and reducing the efficiency and effectiveness of the wider health system overall. Despite this, ambulance staff continue to endeavour to provide their patients with the best possible care, whether face to face or on the end of a phone, and remain dedicated to serving their communities well. It is reassuring that this has been noted within the QW Annual Statement.
Improving the quality of care in the face of increasing demand remains the priority aim for all ambulance services. AACE continues to work closely with NHS England and NHS Improvement to try and address some of the key strategic challenges faced by the ambulance sector, whilst individual trusts working with their commissioners and partner providers, endeavour to find sustainable ways to transform and best meet the needs of their local populations.