The Chair welcomed Mark Docherty, Director of
Clinical Commissioning and Murray McGregor, Communications Director
from West Midlands Ambulance
Service (WMAS).
WMAS had been asked to address members on its
review of community ambulance stations. This item had been raised
at Council on 28 September and all members of Council were invited
to submit questions and lines of enquiry. These were forwarded to
the Ambulance Service, with initial written responses provided and
circulated to members.
Murray Macgregor spoke initially on the
following areas:
- An acknowledgement that WMAS
performance in Warwickshire was not good enough, evidenced by the
performance data provided to members in the circulated pack. This
was disappointing and reflected data from across the country.
- A recent report highlighted cases of
harm due to hospital handover delays. The hospitals serving the
Coventry and Warwickshire area were not the worst offenders, but
there was room for improvement.
- From data there were some 28,500
lost hours of service across the region due to hospital handover
delays, impacting severely on the ability to respond to further
patients. He spoke of the impact for patients, the risk of harm and
for staff, finishing late, affecting their welfare and when they
could commence their next shift.
- This was one of the reasons for the
decisions around closure of community ambulance stations.
- Previously, response targets were
based on the time taken to get to the patient. A detailed review
was undertaken in 2017-18 to look at improvements. Using the
example of a stroke case, it was not about when the paramedic
reached the patient, but when that patient received the specialist
treatment in hospital which determined their likelihood of survival
and a good outcome.
- Community ambulance stations
provided an inefficient system. An outline was provided of the way
the hub model operated and staff had an ambulance checked, equipped
and ready to use immediately for their full shift. Compared to
this, the community ambulance station model had a number of
inefficiencies which were explained and equated to 2½ to 3
hours per site per day. It was estimated that the increased
efficiency from this proposal would enable response to 5000-6000
extra calls per year.
- There was concern that this change
would remove the ambulance cover from Stratford and Rugby. This was
not the case and an outline was provided of the operating model. In
many cases, patients were treated at the scene and did not need
transport to hospital. This meant the ambulance was available in
that locality for the next patient. Data showed that ambulances
based at a community ambulance stations only attended 5% of cases
in their immediate area.
Mark Docherty outlined his background working
in the NHS and spoke on the following
areas:
- His involvement in a document
‘zero tolerance’ raising concerns some nine years ago
about the implications of delayed hospital handovers for ambulance
services.
- Data was provided and nearly 30k
hours were lost due to hospital delays, the equivalent of taking 83
ambulances out of service.
- Across the region WMAS worked with
22 hospitals. He used data from Shropshire to show the significant
increase in delays of over one hour in ambulance turnaround times.
Over the last five years, for that hospital it had increased from
56 to 397 in the first 10 days of November alone. Additionally, the
length of waits at hospitals had increased significantly, in one
case being 14 hours.
- The matrix used to assess the
likelihood and severity of impact of hospital delays. It was
considered that hospital delays would lead to patient deaths. This
was a significant issue which could not be ignored.
- Covid had been used as an excuse.
Whilst it had accelerated the decline in performance, he considered
the current position would have been reached within the next one to
two years without the pandemic. The issue had been raised with many
people over a number of years.
- It was a really difficult position
now and the early signs showed it would be a difficult winter
period.
- The numbers of calls for service
increased year on year. This was the first year WMAS was not
delivering its targets or was not even close to them for some
patients.
- He spoke of the impact of delays in
terms of the number of patients that could be treated by one crew
during their shift.
- WMAS did not have staff vacancies,
but capacity was much reduced as a result of these reported
issues.
- Trainees were attending a much
smaller number of patients, which did not give them the rounded
experience required. The current position would have long-lasting
effects unless a solution was found.
- A local context was provided on the
handover delays at the hospitals serving Coventry and Warwickshire.
The position was relatively better than for some other parts of the
region, although delays were still experienced and there were early
indicators of concern. A comparison was made to Birmingham, where
the delays were considerably more significant.
- He spoke about capacity, the number
of ambulances committed at any time and when there were no
ambulances immediately available to respond.
- He concluded that current response
times were unacceptable.
The following questions and comments were
raised, with responses provided as indicated:
- The Chair and members welcomed the
honest and open approach provided.
- Concerns about the failed
performance targets in CV postcode areas.
- In response to points from
Councillor Pam Redford, discussion about the endeavours to engage
with acute hospitals to address the challenges caused through
delays in patient handover, especially for the Accident and
Emergency (A&E) department. This was a very complex issue, both
in this country and many others. A key contributor was unnecessary
occupancy of hospital beds by people who no longer needed acute
care. Patient flow was key. Both WMAS and A&E were used
inappropriately by many as a first point of care, instead of using
primary care services. The responses showed a need to address this
strategically throughout the NHS as a whole.
- A comparison to the waiting times at
A&E departments, when patients presented, those reported by
WMAS and ambulance waits now meant some people were travelling to
A&E themselves, rather than wait for an ambulance. WMAS gave
patients a realistic appraisal of the waiting times. If people
could travel to hospital themselves, it could be argued that they
did not perhaps need an ambulance.
- Examples were provided of the
initiatives in place, the continual dialogue with acute hospitals,
the use of hospital liaison officers and clinical validation to
triage patients to the appropriate service. Data on conveyance
rates showed the proportion of people using WMAS
inappropriately.
- Mark Docherty gave examples of the
innovations in the region, notably it had the best trauma service,
good outcomes from both stroke and heart attacks and he spoke of
the decisions taken in regard to the vehicle fleet. The figures
could be bland and he urged that they were treated with caution. If
a time target was missed slightly it would be shown as
‘red’ on the data. For serious conditions like a
stroke, it was more important when treatment of the patient started
to give them the best outcome.
- Resolving the current challenges
would require many agencies to be involved.
- There was greater use of emergency
services by younger cohorts than previously. True emergencies
represented about 10% of WMAS work. If other patients accessed the
appropriate health service, this would improve the situation
significantly. The Chair urged the press to publicise the message
to use WMAS appropriately, also highlighting the demographic data
on younger people not using services appropriately.
- Councillor Matecki made points about the closure of community
ambulance stations. Only half of patients required transport to
hospital, so there was a counter argument for efficiency in having
an ambulance in the very south of the county, rather than
travelling from Warwick. A comparison was made to a review by the
Police to centralise staff, which resulted in a reduction in
officer numbers and loss of local services. Assurance was sought
that this review would not similarly reduce services in future.
Whilst the counter argument was accepted by WMAS officers,
generally crews took their break after attending hospital. There
was no reduction proposed in the personnel. In fact the benefits
from the revised arrangements would lead to building cost savings
which would be directed to front line services.
- Regarding the performance data, a
point that a faster response time was likely to lead to the patient
receiving treatment more quickly. It was noted that the best
response time data was for the area closest to the Warwick hub.
Response times for people living close to hospitals were always
good, due to the number of ambulances at hospitals.
- Mr Macgregor gave an outline of the
different response categories and prioritised approach to focus on
the most severe cases. Response times in urban areas were always
faster than for rural areas. Mark Docherty added that service
demands now meant personnel were rarely at the ambulance hub, even
for a meal break. He gave an outline of the process to ensure the
vehicle fleet was maintained, equipped and ready to be used. This
had been a key aspect in meeting the challenges of the pandemic. He
reflected on the benefits of the former community ambulance station
model, but this was no longer sustainable.
- Councillor Rolfe shared her personal
experience following a heart attack. Whilst the WMAS response took
42 mins, the staff had saved her life and she thanked WMAS and the
staff concerned. The Chair thanked her for sharing this personal
account and it gave context on the performance ‘red’
and ‘green’ indicators.
- Councillor Holland paid tribute to
all NHS staff. The current performance wasn’t good enough and
needed a joint recovery plan involving both WMAS and acute hospital
A&E departments. Previously WMAS had said it did not have
enough paramedics. With sufficient staff, up to two thirds of
incidents could be resolved at the scene, reducing the impact on
A&E. Reference also to previous work on quality accounts, a
visit to the Warwick hub, and an outline of how the hub model
worked with the fleet located to ensure a timely response to calls.
Previously, some managers had needed to be operational to add
capacity.
- In response, WMAS now had paramedics
on every vehicle and was the only ambulance service in the country
to do so. It had helped in reducing the proportion of patients who
needed transporting to hospital. The crews were now constantly out
on jobs. Managers were only deployed for complex situations. On the
point about a joint approach to address the current hospital waits,
this needed to be much wider than just WMAS and A&E
departments, to include all aspects of hospitals, primary care,
mental health services and local authorities, to ensure effective
discharge to social care.
- Mr Docherty welcomed the challenge
and ideas put forward, but these were an ‘ideal world’
view. He outlined the actual position using an example in
Shropshire where every ambulance had been delayed at hospital. As a
regional service, ambulances would be diverted from adjacent areas,
but the position was worsening. Context was provided that the
position in Coventry and Warwickshire was relatively not as bad as
for Birmingham. However, the position was much worse than
previously. It was important to recognise the rural geography of
Warwickshire too, which impacted on response times.
- The WMAS representatives then spoke
about the critical time for response to treat a patient in cardiac
arrest and the rapidly worsening prognosis. Community support and
defibrillators were of significant assistance. Typically, in the UK there was a 7% chance of
surviving a cardiac arrest. By comparison survival rates in Denmark
were 25% which was attributed to teaching children CPR in schools
and a much higher number of defibrillators. They needed to be placed every 400 metres to
provide full cover. Reference also to the mapping work with the
British Heart Foundation, so that all defibrillators were
registered and a request for members to spread this message.
- A sense check on peoples’
willingness to do CPR and a request to encourage people to take up
such training and learn where their community defibrillator was
located.
- Councillor Holland reiterated points
from earlier in the discussion, the need for a joint recovery plan
and asked that it be considered by the Committee. Mr MacGregor
stated that this was much wider than just WMAS and A&E
departments, also speaking about the current challenges faced by
acute hospitals.
- The Chair spoke of cause and effect,
the need for the recovery plan to include all stakeholders and
urged a further discussion after the meeting to take this aspect
forward. Councillor Holland repeated that he would like an initial
report at the next meeting.
- Councillor Mills commented that
hospital waits were a longstanding issue and that some people made
inappropriate requests for service.
- Councillor Cooke asked how WMAS
checked that service requests were appropriate and the potential
for a public education video. Mr Docherty replied that public
education was difficult and from a previous endeavour had actually
increased unnecessary calls for service. An example was used of
referrals from care providers ‘out of hours’ for
incidents involving frail elderly people. These often resulted in
the person being admitted to hospital, when other services may have
been more appropriate, but they were not available 24 hours per
day, seven days a week. The situation was exacerbated over the
Christmas period, due to the closure of other services.
- Councillor Roodhouse suggested that
a task and finish group may be a useful method for discussing the
recovery plan. He considered that poor communications had
contributed to the public reaction to the operational decision
regarding closure of the community ambulance stations. He referred
to a WMAS board paper and asked for an update on the regional
discussions to address the current challenges. Similarly, an update
on the clinical validation teams in call centres was sought. In the
Health and Wellbeing Board which preceded this meeting, approval
had been given to the Better Care Fund submission. He quoted from that paper on the implications of
falls and the significant number which resulted in calls to WMAS.
This needed to be picked up as part of the integration
arrangements. He considered that WMAS should be involved a lot more
in those discussions and that WCC could assist with communications.
In regard to the NHS111 service, difficulties were experienced with
calls not being answered, so people may then ring 999 instead.
- Mr MacGregor referred to a recent
letter from NHS England to acute trusts and others asking them to
address delayed hospital handovers, which had highlighted this
issue. He reminded of the recent report on patient harm resulting
from such delays. The clinical validation team was working well and
improving still further. In September it directed lower priority
requests to more appropriate services in 12,000 of 20,000 cases
where no ambulance was required. In October it was 18.9% of such
calls. An outline was given of how this was undertaken through
advice or triage. WMAS now had the highest non-conveyance rate in
the country.
- On the NHS111 service, Mr MacGregor
advised that WMAS was commissioned to handle 1.2 million calls per
year but was now taking 2 million calls, causing immense pressure.
There was no additional funding for the extra calls. During the
height of the pandemic, a clinical decision was taken to focus on
the emergency 999 service, using staff from the NHS111 service
which had impacted. Extra call handlers had been and would continue
to be recruited to address the known problems, even if it put WMAS
into deficit. The service was starting to recover as a result of
this action. Integration of the 999 and 111 call handlers had taken
place and the benefits of this approach were explained. There was a
continual increase in calls to the NHS 111 service and the public
were now being encouraged to use its online service first or the
NHS mobile telephone application.
- Chris Bain thanked the speakers for
the clear and candid approach at both this meeting and a previous
regional Healthwatch meeting. He agreed that resolving the current
challenges required a system-based response. NHS111 and the 999
service were part of that response. HWW was undertaking a survey of
those using NHS111, with a focus on carers using the service during
the pandemic. Access to GP doctors remained an issue. At acute
hospitals there were concerns about bed occupancy levels, lengths
of stay and safe discharge arrangements to other services. It
needed an ICS response for a joint recovery plan and could not be
produced by WMAS alone. It also needed to include the Coventry and
Warwickshire Partnership Trust.
- Mr Docherty welcomed these
contributions, also praising WMAS staff for their work through the
pandemic. Staff were fatigued, fragile and some had received verbal
abuse. They needed space and help to recover and WMAS was
undertaking a range of actions to improve services and help its
staff. He reiterated the increasing volume of calls to the 111
service. Mr Docherty spoke more generally about Covid and
influenza, encouraging people to be vaccinated.
- Chris Bain drew a distinction
between A&E attendances and admissions. Primary care had a
significant role to play.
- Councillor O’Donnell also paid
tribute to WMAS for the service provided for a family member. She
agreed that the recovery plan needed wide input, spoke about
hospital discharge arrangements, the need for better communication
and the additional challenges caused by Covid. She was concerned
about the lack of experience for trainees. Mr Docherty gave an
outline of the different training offers and the option to extend
training periods. Examples included a new paramedic masters’
degree course, simulation training and hospital placements to get
maternity experience. Remote supervision provided another option
using technology to connect to hospital-based services to receive
guidance where required. Murray McGregor gave a further example of
video calls made to multi-disciplinary teams, improving diagnosis,
providing prompt treatment or referral to a specialist. Such video
technology was also being considered for the NHS111 service and
would assist call handlers.
- Councillor Humphreys asked for more
information about community first responders (CFR), the total
number of people, total hours of service and where they were
located. Mr McGregor offered to provide specific information for
Warwickshire after the meeting. CFRs were volunteers and WMAS was
undertaking a campaign to recruit more, having secured an extra 400
over the last year. Following a review, CFR activity was focussed
on areas where they could have most impact, responding to serious
medical conditions such as cardiac arrest and stroke. He encouraged
councillors to seek to establish a CFR scheme in their communities.
Further points were the standard training qualification for all
CFRs and their importance in rural communities to provide a timely
response.
- Further information was provided
about the national category system for prioritising calls for
service.
- Mr Docherty reiterated that WMAS was
not happy with the current response times. He outlined the WMAS
operating model, the allocation of ambulances on a prioritised
basis, the potential service demands currently and risks of harm
for some patients if no ambulance was available to respond. In very
serious cases such as a stroke those delays could result in the
patient’s death or significant long-term impacts. These
delays were directly attributed to ambulances being delayed at
hospitals.
- Councillor Kettle questioned if the
lower category cases should be considered as a crisis necessitating
a 999 call or indeed whether an ambulance should be sent if there
were other options for the patient to be transported to hospital
more quickly. The officers spoke of the surge in service demand in
the summer. Councillor Kettle asked if there were any aspects the
Council should be considering. A concern about the response time
data for south Warwickshire which was significantly worse than for
some other areas of the county. He also asked what impact the
revised arrangements would have for rural areas in south
Warwickshire and whether response times would worsen.
- Mr Docherty urged caution in the
interpretation of call categories, which were used by WMAS to
prioritise the service response. Some people may not clearly
express how unwell they were, whilst others could overstate their
symptoms, to get more urgent attention. He gave a number of
examples to demonstrate this. On rural response times, it was hard
if not impossible to meet the seven-minute target for all areas and
this could not be guaranteed even if there was a significant
increase in crew numbers and the ambulance fleet. The data on
response times would continue to deteriorate if the current
hospital delays were not addressed.
There was a need to have honest conversations. He spoke of wider
issues including the age profile of people in rural communities,
the impact of deprivation on some communities and there would be a
variance in response times for the most rural areas.
- Mr MacGregor spoke about the high
number of Covid cases still, but people had ceased to wear face
coverings. Wearing face coverings had also contributed to there
being fewer flu cases last year. It was known that some people had
not received Covid or flu vaccinations, but by following health
advice the situation would be better. The NHS was in difficulty and
everyone had a role to play in looking after themselves and
others.
- The Chair thanked Mark Docherty and
Murray MacGregor for their honesty and for responding to
members’ questions. She considered the opportunity for the
wider Council membership to submit written questions was helpful.
If there were any further questions, these could similarly be
forwarded to the WMAS officers.
- The Chair stated that GPs need to
“step up”; opening their doors and delivering the
services that they have a duty to. She added that throughout the
Pandemic other arms of the health service have risen to the
challenge. The same could not be said for GPs. Members of the
committee were reminded that a task and finish review of GP
services is about to commence. The TFG may wish to include within
its remit how GP activity had an influence on wider NHS issues.
Some people used A&E services because they could not get a GP
appointment. There was an education piece, which should start at
school for example with CPR training and correct use of services.
The public needed to take more responsibility themselves. They
could access services by video call and wearable technology/
augmented reality may be of use too. The Committee would always be
a critical friend and whilst some issues may not be agreed on, the
open and honest dialogue was valued. To the Portfolio Holder,
Councillor Bell, she spoke about discharge support and providing
wraparound services on a 24 hours per day, seven days per week
basis. This was something that the county council’s services
should adapt to, to match NHS colleagues. Emergency response
systems out of hours were perhaps not as effective as they could be
to get people into and out of an acute hospital. The Chair praised
the Warwickshire Fire and Rescue Service hospital to home scheme,
having seen this operate. It could perhaps be expanded and add
capacity to WMAS. It had been established that ‘999’
calls were subjective and that the response time data could be
misleading. The Chair asked that details for the defibrillator
registration scheme be provided for wider circulation, also
speaking on CPR. She closed this item, thanking Mark Docherty and
Murray MacGregor for their time and members applauded.
Resolved
That the Committee notes the update from
West Midlands Ambulance
Service.