Agenda item

The Committee received an update from WMAS on 17 November 2021. This item will provide an update on performance.

The Committee received an update from WMAS on 17 November 2021. Pippa Wall, Head of Strategic Planning for WMAS provided an update on performance data since that meeting, through a presentation covering the following areas:

• Incidents, transport and conveyance rates year on year.
• Coventry and Warwickshire hospital handover delays of over fifteen minutes – the total hours by month.
• Operational demand and handover delays.
• Hospital handover delays of over fifteen minutes and cohorting vs operational performance. A series of charts showing the position for priority categories 1,2 and 3.
• Two further slides were provided showing handover delays for University Hospitals Coventry and Warwickshire (UHCW) and for Warwick Hospital. A similar slide for George Eliot Hospital would be circulated.

The Committee was invited to submit questions and comments, with the following points raised:

• Difficulty in reading and interpreting the slides. It was noted that these had been circulated ahead of the meeting.
• The slides showed a concerning position. It was interesting to note that during the peak of the pandemic services were coping but performance had worsened over the last year. The causes were questioned.  Pippa Wall agreed that it was a bad position and was difficult for front line staff assisting patients. People were waiting longer for WMAS to arrive, and the situation was unprecedented. An outline was given of contributing factors, including Covid, the recovery work of NHS impacting on other services and people presenting with more acute conditions. There was staff fatigue and sickness, some people were leaving the services and reference to ongoing recruitment as well as continued infection control measures. Ambulance delays at hospitals were also mentioned.
• The data for the most serious (category 1) calls was considered shocking and the trends showed the position was worsening. It was hoped the position would improve. Details were provided of the escalation processes to raise these concerns and the dynamic response approach to address concerns where possible. This situation required a holistic system response as hospitals were similarly facing many challenges.
• The open and honest approach was appreciated.
• Chris Bain of HWW agreed this was a system issue for the ICS. He spoke about separating attendance at the Accident and Emergency (A&E) departments from resultant admissions. There was more chance to influence why people attended A&E and avoid unnecessary attendance. The impact on patients was not covered and should be. Delays could be linked to readmission rates, lengths of stay and impacts on discharge. Chris asked how the situation would be recovered and by who. He was not clear if there were any system plans in place for recovery.
• Pippa Wall agreed on the points about patient impact. WMAS was a data rich organisation and could make more use of this data to give an integrated picture and insightful messages. An increasing number of complaints were being received. She spoke about the monitoring of performance data around impact for patients who were critically ill. This could be researched to provide an answer to the questions raised. Addressing the current position would require action by a number of organisations. Hospitals would similarly have their own action plans and there were national mandates to reduce ambulance handover delays. Pippa spoke of the current delays in some parts of the region and the risks for patients who were waiting for an ambulance to arrive. There was an impact on the call centres too as people sought an update on the crew’s arrival. Reference also to the 111 service and subsequent requests for an ambulance to sent. There were attempts to reduce conveyance to hospital where possible and the proportion of patients taken to hospital had reduced. Also, the ‘hear and treat’ service resolving issues over the telephone had contributed in reducing conveyance to hospital. However delayed arrivals meant the condition of some patients had worsened.
• The presentation data was difficult to interpret just showing a number of spikes. It should include more context, for example on the impact of a delayed handover or reduced recovery rates. As WMAS was ‘data rich’ it was questioned what analysis took place to make use of this data. The points were noted. It would be useful to add events such as commencement of the pandemic to the timeline to show causal effect. It was also important to show trend and correlation data.  Examples were provided of the information sources available to WMAS, the software system and dashboards which enabled investigation of this data, down to clinician level and the treatment supplied.
• It was questioned how GPs could assist in reducing the attendance numbers at A&E departments. A question about the coordination of individual plans and strategies to address the current situation. Pippa Wall confirmed there were system wide meetings where providers discussed their respective challenges. WMAS wanted to reduce hospital handover delays to improve response times. It did provide information to GP surgeries on patients requesting an ambulance. All parts of the NHS were ‘fire-fighting’ currently, attempting to address their respective concerns, but it was challenging. The member viewed that this could be addressed by working together to find a solution.
• More information was sought about how call categories were defined and the information provided to the call handler was interpreted. There were significant differences in response target times. An example was used of a case involving a serious incident, where it was felt the wrong call category had been assigned. Pippa Wall responded that the categories were determined nationally and were reliant on information given over the phone. These were highly emotional situations. Call assessors used a nationally assessed script to ask questions in determining the priority of the call.
• A concern about people calling for an ambulance inappropriately. 
• An analogy was used to demonstrate the need to ‘unblock’ the system. There was a need to support social care, to put it on an equal footing to the NHS and include it as part of the system approach to addressing the current problems. Nigel Minns added that the whole system had to work together on this. He spoke about the significant involvement of social care, the daily discharge meetings and the low proportion of people discharged from hospital who needed onward social care. Too much time was spent focussing on the discharge of patients and there should be more of a focus on the patients presenting at hospitals. This did need a system approach, involving the CCGs and primary care. It was taking place, but there was always room for improvement.
• A question on the proportion of hospital beds and wards that were now in use. Reduced capacity impacted on hospital admission efficiency and delayed handovers for WMAS personnel.
• Concerns for dementia patients as family members were not permitted to travel in the ambulance with them. It was agreed that for dementia patients and relatives, transfer to hospital could be challenging and stressful. They were allowed to be accompanied prior to the pandemic and an update would be sought on this aspect, whilst noting the ongoing measures around infection prevention.
• A breakdown was sought in the variance for response times between urban and rural areas, acknowledging that the distances involved may increase the time for the ambulance to arrive.
• Data showing averages wasn’t useful. A number of examples were provided of lengthy waits for an ambulance to arrive. Questions about the impact of delays for patients, and if the wrong category was applied by the call handler assessing the urgency of that case, a longer wait could result. From the data available, it was important to look at outcomes, not trends and to monitor the accuracy of the call category allocation.
• Pippa Wall acknowledged the points raised. There had always been a longer response time to reach rural areas, but the current position made this more challenging. There was an audit process of the call handling and summary information could be supplied. The councillor requested more granular performance data. This had been provided on request previously, but given the time taken to produce it, would need to be useful to a wider audience. Data was also available on the national performance standards. The current performance level showed a lot of ‘red’ indicators where targets were not being achieved. There were occasions when WMAS was not able to provide a service, even in urban areas. The Chair confirmed that postcode-based data had been supplied previously.
• A need to formulate an action plan and to work jointly to address the current position. There had been a worsening performance trend for some years. A solution may be for additional WMAS staff, who could treat patients without needing to convey them to hospital. The member recounted attending the WMAS Hub in Warwick and seeing the operational challenges faced. He quoted examples of good practice such as the active monitoring of ambulances waiting at hospitals. Such timely information was essential to good decision making. It was confirmed there was no spare capacity in the system now. In the subsequent item, an outline would be provided of the initiatives being employed by WMAS to alleviate pressure. Comparatively, WMAS was the most successful ambulance trust in the country, and the position elsewhere was even worse. However, WMAS was struggling to meet targets. There was a strong recruitment and training model, which assisted with capacity.
• A need for preventative work and community services to reduce the need for hospital admissions.
• A councillor shared a personal example to demonstrate the challenges faced and praised the professionalism of paramedics. On arrival after a nine hour wait the staff were concerned that the wrong call priority had been allocated. There was a need for more flexibility in assigning a category as some lives had been lost due to incorrect judgements. For future items, having someone involved in that service area to attend the meeting would be helpful. Warwickshire had an older than average community, with many located in rural areas and there would be more falls. She spoke of the alternate service pathways or a community team to attend for such incidents. Research of 15 parish councils had resulted in a number of similar issues being reported. From the report, it was questioned if the response time data and statements made within the document were accurate. The needs of elderly patients and those with dementia should be taken into account when considering categorisation. The points were acknowledged and would be responded to under the subsequent Quality Account (QA) item. Reference to alternative pathways and engaging community first responders (CFR). These provided a valuable additional resource for situations like the one reported. However, the length of wait was not acceptable and previously would have been an exception. It was known that symptoms worsened due to such delays compounding the treatment needs and length of hospital stay required. This was impacted by crews being delayed at hospital. The councillor responded that in this case a complaint was urged by WMAS staff.

The Chair gave a summation that ‘one size fits all’ did not work nationally or within Warwickshire. There was a need for flexibility within the system to take on board local feedback. Also, a need for an end to end reform of the NHS was evident, a need for accountability and improvement in outcomes, and a need to accept the issues within the system.

Resolved

That the Committee notes the performance update from West Midlands Ambulance Service.

At 12:55pm the Chair moved a motion to suspend standing orders to enable the meeting to continue beyond three hours’ duration. This was duly seconded and approved by the Committee. A brief adjournment took place for five minutes.