Agenda item

To receive a joint presentation from representatives of the Welsh Ambulance Service Trust (WAST) and Betsi Cadwaladr University Health Board’s (BCUHB) GP Out of Hours Service on their performance and the work currently being undertaken jointly to improve the care pathway for patients

 

10.10am – 11.10am

The Chair welcomed representatives from the Welsh Ambulance Service Trust (WAST) and Betsi Cadwaladr University Health Board’s (BCUHB) GP Out of Hours (OOH) Service to the meeting to give a presentation on how both services were working together to improve outcomes for patients through the delivery of a clinically appropriate response rather than focussing on meaningless time targets.

 

Through the medium of a PowerPoint presentation WAST representatives explained the transformation programme which had taken place in the ambulance services in Wales in recent years.  They highlighted a number of the positive developments that had taken place as part of this transformation programme and shared their experience of implementing the Clinical Response Model (which determined the most appropriate response to deploy to an emergency callout). They recounted the lessons learnt as part of the implementation process and their future aspirations for improving the care pathway for patients.  

 

Members were also given an overview of the position of the Clinical Response Model in context of the wider organisational and system change within the health service in Wales.

 

WAST was commissioned by all health boards in Wales to provide an ambulance service to transport patients to their establishments and to deliver appropriate health intervention services en-route to those establishments.  Across Wales the Service dealt within the region of 1,300 emergency calls a day.  The Service - which was Government funded - was free at the point of need. 

Similar to other health and social care services and partly due to demographic changes, it was under constant pressure as the demand for its services was continually increasing.  That increase in demand had highlighted for the Ambulance Service the need to change the operating environment within which they worked. The focus was diverted away from meeting non-meaningful time targets, to improving the experience for the patient when they arrived, to treat them with a view to improving the outcomes for them in the long-run. 

The new Clinical Response Model was at the heart of the transformation programme.  WAST was the first Ambulance Service to adopt this model, however services in both England and Scotland were now following WAST’s lead.    During the presentation WAST representatives:

·         described the ‘designing ambulance into unscheduled care’ process and the agreed Red, Amber, Green (RAG) prioritisation procedure - which was designed to be clinically focused, prudent and safe for all patients;

·         advised that whilst as a Service they had various targets set for specific tasks or areas of work, the only target they were measured against on a national basis by the Government was the 8 minutes target set for responding to a call allocated ‘Red’ status – the highest level emergency;

·         advised that reducing demand for the Service was extremely difficult.  Data evidenced an increase in demand year on year, with future projections also estimating a year on year increase in demand on the Service for the foreseeable future.  Consequently a plan was needed to try and better manage the demand;

·         explained that the Clinical Response Model trialled and adopted in Wales included working with partners - i.e. Health Boards, GPs, Social Services, Police, Fire and Rescue Service etc. - to effectively and appropriately support people who called the Ambulance Service on a regular basis (Frequent Callers). 

For example clinicians were now located in Police and Fire & Rescue Services’ Control Centres to help manage calls received at those centres with a view to appropriately prioritising the Ambulance Service’s response to those calls.  The ‘Hear and Treat’ approach, during which appropriately qualified paramedic and nurse clinicians would undertake telephone assessments  and determine the most appropriate method of treatment for the patient was proving to be successful. 

The statistics on the number of calls received by the Service during the period between January and March in 2017 and 2018 and the number of conveyances by ambulance to hospital illustrated the success of the new Clinical Response Model. Despite the number of calls received by the Service increasing the number of conveyances to hospital by ambulance had reduced, thus releasing emergency ambulances to be available to respond to critical emergencies;

·         informed members that WAST had a target of 65% set for the number of RED category response calls to be reached within 8 minutes in Denbighshire.  The 65% target took into account the rural nature of the county.  Between January and May 2018 the Service had exceeded this target and was responding to calls in this category within the 8 minute timeframe in 80% of the cases, with performance varying between 72.7% and 85.4%; and

·         gave statistics on the number of ‘ambulance hours lost’ due to the time taken outside Accident and Emergency Departments to ‘handover’ patients to the care of the Health Board.  The number of ‘hours lost’ in the BCUHB area was consistently the highest in Wales.  However, a lot of work had been undertaken at Ysbyty Glan Clwyd with a view to improving performance in this area.  This approach had proved successful and was now being rolled-out to the other Accident and Emergency Departments across North Wales;

 

WAST’s Regional Clinical Lead (Consultant Paramedic) for North Wales gave an overview of a pilot project undertaken, the aim of which was to test whether a rotational model of working enabling the effective deployment of Advanced Paramedic Practitioners (APPs) could effectively reduce unnecessary hospital admissions. 

 

The pilot, which took place between October 2017 and March 2018 involved 10 APPs, one of whom was located in the Clinical Call Centre (CCC).  As part of the trial the APPs were utilising the ‘hear and treat’ approach to determine the best care pathway for the patient. 

During the 4 month trial period, without any adverse impact occurring:

·         1045 ‘top 3 code’ incidents were dealt with.

·         30% of the cases were resolved and closed by the APP. 

·         Only 30% of the calls required an emergency ambulance to transport them to hospital,

·         70% of the calls did not require to be admitted to a hospital Emergency Department. 

Consequently 307 ambulance conveyance journeys had been avoided, equating to 732 ambulance hours (or 61 12-hour shifts) saved back into the system.  95% of contacts had been resolved with a single episode of care, with patient satisfaction levels being recorded as 98%. 

 

As the majority of APPs were currently based at either Ysbyty Gwynedd, Bangor or Ysbyty Maelor, Wrexham a business case was currently being prepared to extend the service across North Wales.  Work was also underway with a view to training APPs to an even higher level - that would permit them to prescribe medications above what Patient Group Directions (PGDs) guidelines currently permitted them to prescribe. 

 

The potential of locating APPs in primary care situations on a rotational basis was being explored aimed at providing support to primary care services.  Unlike other medical and nursing professions paramedics were currently employed on a single-grade basis.  Exploration of the potential to develop career progression pathways, with the possibility of introducing pay grades which would reflect experience, specialist skills etc. were underway. 

 

Recently the pilot project had been awarded the Healthcare People Management Association Academi Wales Excellence in HR award and it had been shortlisted for the Improving Patient Safety Category award at the NHS Wales Awards.

 

WAST’s Executive Director of Quality Safety and Patient Experience (Nursing) and BCUHB’s  Executive Nurse Director, and Senior Nurse for the GP Out of Hours Service (OOH) for Conwy and Denbighshire outlined the Alternative Care Pathways pilot, launched in October 2017, and the work of the GP OOH Service in alleviating pressures on Emergency Departments and hospital in-patient services. 

 

Health and Social Care Services throughout the UK experienced the highest demand ever on their services during the winter of 2017/18.  The Alternative Care Pathway process alleviated pressures on Emergency Departments by directing or conveying patients where appropriate to Minor Injuries Units (MIUs), which were generally closer to the patient’s home. 

 

At the MIU’s they could be administered the appropriate treatment by a nurse practitioner or a senior nurse practitioner, and/or assessed for referral to more specialist services - i.e. Cardiac care, Diabetes Management,  Alcohol & Drug Services, Social Care Services etc.  MIUs had a far better environment for the patient than a busy Emergency Department, particularly if they had complex needs. 

 

The Health Board worked closely with GPs and the GP OOH’s Service with regards to referring patients to GPs for continuing healthcare management. Whilst the GP OOH Service worked closely with the Health Board to deal with patients who presented themselves at the Emergency Department when GP surgeries were closed etc.

 

The GP OOH Service, a dedicated professional line available to WAST, other healthcare professionals - NHS Direct, Districts Nurses, Marie Curie Services etc. - and the public for GP advice was available between 6.30pm each evening and overnight until 8am from Monday until Friday, and between 6.30pm on a Friday and 8am on a Monday for weekend cover. 

 

All telephone calls received by the Service, including those from paramedics of which there were in the region of 80 to 100 per week, were reviewed using the information/history given by the caller before the most appropriate clinical pathway was determined.  Consideration was currently being given to developing the Service further by having a GP OOH’s presence within Denbighshire’s Single Point of Access (SPoA) Service.  That would benefit both the GP OOH Service - by being co-located with other health and social care service services and agencies - plus it would assist the Council to meet the requirement of having a minimum of two people available in the Service during weekends etc. 

 

With the changes in the demography of the population and an increasing number of older people living in the community, frailty was becoming more prevalent.  This in turn increased the demand on services, therefore in order to manage that demand it was crucial that all health, social care services and the voluntary sector worked closely together to meet and manage the growing demand by devising alternative care pathways to support individuals.

 

Responding to members’ questions WAST and BCUHB representatives along with Denbighshire’s Lead Member for Independence and Well-being and Head of Community Support Services:

·         advised that the direction of travel outlined by WAST and BCUHB in their presentations fitted in well with what the Council wanted to achieve, particularly with managing the SPoA Service;

·         advised that the main issue for social care services was waiting times for ambulance to convey individuals assessed as requiring detention under the Mental Health Act;

·         advised that the WAST was currently looking at its Public Health Plan to make sure it underpinned all of its operational plans and its Well-being Plan;

·         agreed that there was a need and a duty to educate and communicate with residents on when to contact the Ambulance Service and which other health or social care services should be considered before calling 999;

·         confirmed that all MIUs in Denbighshire, and across North Wales, had been involved with the Alternative Care Pathways pilot;

·         confirmed that WAST was working closely with the Fire and Rescue Service on a number of initiatives.  There was still an ambition to introduce co-responding across North Wales, where both Fire and Rescue Service staff and Ambulance Services personnel would respond together to an incident with a view to commencing appropriate treatment to the patient immediately the first emergency vehicle arrived at the scene of an incident.  Both services also had data-sharing arrangements.  Fire and Rescue Service staff undertaking Home Fire Safety Checks (HFSCs) also identified potential trip or slip hazards noticed within a person’s home, any signs of ill-health, abuse or neglect, egress issues and prepared evacuation plans in the event of an emergency all of which may be valuable information for other services, such as the Ambulance Service if they were deployed to that particular address at a later date.  WAST also worked with the Police and Fire and Rescue Services in relation to safeguarding concerns and/or signs of dementia.  The more information agencies could share about individuals with whom they engaged with, the better the level of care other services could provide for those individuals when the need arose;

·         acknowledged that APPs were not GP trained, they were not expected to have the knowledge and skills set of GPs.  Their skills were more extensive than those of a paramedic and therefore they were a complementary resource that could deliver early intervention and care to a patient and potentially prevent the need for further more complex medical intervention later.  They also had the knowledge and experience to determine the most appropriate next stage care pathway for the patient, if one was required;

·         concurred with Committee members that the volunteer First Responders were key in rural areas as they had the skills to identify cardiac arrests, access to defibrillators and the skills to use them, as well as the knowledge to deal with trips and falls;

·         advised that the number of beds available at each Accident and Emergency Department was a decision for the Health Board.  However, the demand for beds in these departments varied on a daily basis and were extremely difficult to predict i.e. the Accident and Emergency Department at Ysbyty Glan Clwyd had anticipated 60 ambulances to convey patients to the Department the previous day, the actual total at the end of the day was 68 ambulances conveying patients to the Department.  Despite receiving more ambulances than expected the Department had been able to deal safely with the patients;

·         informed members that the delay encountered in handing patients over to district general hospitals stemmed from the Health Board being unable to discharge patients to other places of safety i.e. their home address, community hospital etc.  Generally, with respect of discharging people to their home address the problem was delays encountered in arranging care packages for the individuals concerned;

·         confirmed that with a view to assisting residents to access the right services with their first phone call WAST was exploring the feasibility of establishing a ‘Clinical Hub’ in North Wales.  The intention was that people who dialled 999 or 111 would be directed to the correct service.  A similar service already operated in the Abertawe Bro Morgannwg Health Board area.  It was hoped that the first phase of this service would be available in the BCUHB area in time for the forthcoming winter, with a view to building upon the services accessible via the Hub in future;

·         advised that Ambulances on standby to respond to emergency calls were located at both Ambulance Stations and in roadside laybys.  Decisions in relation to their location was taken based on achieving the optimal emergency vehicle coverage for the area at that particular time;

·         explained that the Symptom Checker facility on the NHS Direct website was a particularly useful feature for the public’s use.  In future, with technological evolvement other useful services may become available for mobile devices;

·         confirmed that WAST and the Health Board were working closely with all 6 SPoA services in North Wales and referring cases to them.  It was expected that once it was up and running the new Clinical Hub service would also refer people to the SPoA for their area.  However, it would be useful for WAST. BCUHB and other regional and sub-regional services to have a single dedicated telephone number that would connect them to SPoA rather than as at present having six different telephone numbers for them.  Nevertheless, they were of the view that closer working between all agencies was crucial if demographic pressures were to be effectively managed;

·         advised that WAST representatives met on a regular basis with the Welsh Government (SG) and the Chief Executives of the seven Health Boards in Wales; and

·         confirmed that the proposal to rollout the APP Service across North Wales now formed part of WAST’s business plan for the forthcoming year.  The Service and Health Board were also exploring the viability of extending the opening hours of MIUs and health service operated pharmacies.

 

The Corporate Director:  Economic and Community Ambition undertook to make enquiries regarding any data which the Council could share with WAST -as he was aware that the Planning and Public Protection Service for example held information following Environmental Health visits or enforcement visits to Houses of Multiple Occupation (HMO).

 

WAST and BCUHB representatives indicated that if Committee members wished to visit the Accident and Emergency Department at Ysbyty Glan Clwyd, they would gladly facilitate a visit.

 

At the conclusion of the discussion the Chair thanked WAST and BCUHB individuals for attending, giving their presentation and answering members’ questions.  He also congratulated them on the improvements made to the Ambulance and Out of Hours Services and encouraged them to continually aim to improve services for the county’s residents, as health services touched the lives of all residents.  It was:

 

Resolved: - subject to the above observations to receive the presentations by the Welsh Ambulance Service Trust the GP Out of Hours Service