Agenda item

In attendance for this discussion were:

West Midlands Ambulance Service Foundation Trust

Dr Anthony Marsh, Chief Executive Officer

Michelle Brotherton, General Manager for the West Mercia Area

The Chairman welcomed the representatives from West Midlands Ambulance Service Foundation Trust (WMASFT).

Dr Marsh gave a presentation to update the Health Overview and Scrutiny Committee (HOSC) on the work of WMASFT, including firmographics, vision, achievements, national and local performance/costs, activity growth, hospital transformation, hospital handover, Community Response Schemes and innovation plans.

A map indicated the diverse area covered by WMASFT, which included Worcestershire. The Service attended over 532,000 emergency patient journeys annually, and served a population of 5.6 million, over 5000 square miles, of which was 80% rural. With a budget of around £250 million, the service received 3,500 999 calls per day, had around 1000 vehicles, 5000 staff, 800 volunteers and 4 Air Ambulance Helicopters.

Worcestershire now had two Hubs in Bromsgrove and Worcester, 7 community ambulance stations and a network of community response posts.

There was a clear vision of 'Delivering the right patient care, in the right place, at the right time, through a skilled and committed workforce, in partnership with local health economies'.

Dr Marsh highlighted the WMASFT's achievements, which included:

·       only Ambulance Service to achieve each of the national emergency access targets for 2015/16, and also the best performer for each

·       only Ambulance Service to be ranked at Segment One of the Single Oversight Framework

·       top performing Ambulance Service in the Country

·       one of four Ambulance Trusts to achieve statutory financial duties

·       no paramedic vacancies (there were around 2,500 nationally) – through working alongside local universities to recruit and train local people

·       lowest sickness absence rate in the Country

·       highest paramedic skill mix ratio in the Country – included on 90% of ambulances

·       best fleet in the Country

·       lowest number of calls waiting, with over a million 999 calls a year

·       Third lowest cost per incidence

Overall activity continued to increase, with New Years' Day 2017 being the busiest day on record, and the annual growth for 2016/17 was projected to be well above the current figure of 3.8%. There was a correlation between colder weather and increased demand for issues such as respiratory problems and falls, but 2016/17 had not been that cold so far.

Dr Marsh was confident of being able to maintain efficiency savings whilst ensuring statutory duties were met, and in real terms around £50million had been saved through cost improvement plans since 2012/13.

The work involved to make these achievements should not be under estimated; WMASFT was very proud but in no way complacent.

WMASFT continued to be part of transformation plans for Worcestershire's Acute Hospital Services although there were undeniable pressures and the transfer of services from Redditch to Worcester at times challenged operational ambulance performance due to increased journey time and hospital handover delays.

Hospital handovers were a real problem for every Ambulance Service across the country and Dr Marsh was involved in national work on this. Handovers in Worcestershire were particularly problematic, especially Worcestershire Royal Hospital and a table showed average and longest times from April to December 2016, the number of lost hours (over 15 minutes) and the number of over 1 hour handovers. Handovers to Worcestershire Royal hospital averaged of 20 minutes, the longest time being 5 hours, 24 minutes. Over hour delays were considered unacceptable and the fact that nearly 150 patients had waited over an hour to be handed over to Worcester Royal Hospital in December was disgraceful. WMASFT monitored hospital ambulance activity to try and stop queues and met regularly with hospital colleagues to try and find ways to improve this.

Dr Marsh strongly supported the practice of taking patients to a specialist base, and there was strong evidence of greatly improved outcomes for those suffering major trauma conditions such as stroke or cardiac arrest – however it was important that ambulance services were appropriately compensated for the additional journey times.

WMASFT continued to monitor the quality of its services, for example journey response times, but also training and technology such as electronic care records. There were high expectations of paramedics, in dealing with a vast range of conditions. The whole of the Trust outperformed the national average for Ambulance Clinical and Quality Indicators.

Dr Marsh had been highlighting the need to revisit targets, to ensure they were still relevant and backed by clinical evidence; whilst he believed current targets had served the NHS and patients well, many had been introduced over 10 years ago. WMASFT was one of three Ambulance Services involved in the national Ambulance Response Programme, working alongside NHS England and Sheffield University, which was due to report in the spring.

The HOSC was shown performance against response times for the four categories of incident across the period 12 October – 31 December 2016, which for category 1 was broadly running at 65%.

The work of the Community First Responders Scheme was very important and appreciated, since there was a high degree of rurality across the West Midlands. Responders did a great job, which WMASFT was keen to support. Dr Marsh was aware that Worcestershire County Councillors had supported installation of defibrillators and encouraged members to think about any areas which were not facilitated, as there was very strong evidence that defibrillators saved lives.

Regarding innovation and collaboration, Electronic Patient Report was now live regionally, and the fleet was being developed with new command and control vehicles and concept emergency ambulance. WMASFT invested heavily in paramedic recruitment and training to equip them to deal with whatever, wherever. Dr Marsh was confident the Service had robust arrangements in place to cope with winter pressures, in spite of the significant challenges from hospital handovers.

Main discussion points

·       The Chairman and other HOSC members paid tribute to WMASFT staff and service and were impressed by the information and honesty about its performance and operations.

·       Several HOSC members who were also members of Hereford and Worcester Fire Authority asked about opportunities for closer working with Hereford and Worcester Fire and Rescue Service (HWFRS) in terms of co-responding to incidents, particularly in rural areas which were a concern as they took longer to reach. 

·       Dr Marsh confirmed that WMASFT had offered opportunities to HWFRS engage and train fire fighters as community first responders, to assist in rural areas. Another possibility was for WMASFT to place staff at underused fire stations.

·       Jon Pryce, Area Commander for Hereford and Worcester Fire and Rescue Service was present and was invited to join the discussion and advised that whilst the offer from WMASFT may interest a small minority of staff, HWFRS would welcome further options to maximise staff capacity and assets; fire engines were equipped with defibrillators which provided options for collaborative work beyond the use of volunteers. Referring to a national consensus agreement between the Association of Ambulance Chief Executives and the Chief Fire Officers Association which included co-responding schemes, he was aware of 30-40 collaborative scheme agreements where fire and rescue services engaged with Ambulance Services, by responding in parallel to provide assistance at the scene while the ambulance may be en route.

·       Dr Marsh was aware of different schemes elsewhere, but highlighted the need to protect each organisation's primary function; what could occur if lives were put at risk by fire engines responding to medical, rather than fire related incidents. He also stressed that training for paramedics was at a much higher level than community response training.

·       Both organisations were clear on their commitment to work more collaboratively to save even more lives, and everyone hoped that the discussion had clarified agendas, which it was hoped would be helpful in identifying further scope.

·       Where practical and appropriate, ambulances may take minor injured patients to minor injuries units (MIUs), although it was pointed out that if minor injuries patients were taken to A & E, they would go to the reception area, and therefore not impact on hospital A&E handovers.

·       Dr Marsh felt that an ageing population was fuelling increased demand for Ambulance Services, however an important factor was also the public's high expectations about availability of services in general; the internet meant that people were used to instant access and action.

·       The assumption that a 999 call would lead to the patient being taken to A&E was not true; WMASFT's paramedic numbers contributed to the Service having one of the lowest hospital conveyance rates in the country at only 56%. Despite this, WMASFT were dealing with much higher demand.

·       The process for preparing and cleaning ambulances in between patient journeys was explained.

·       Dr Marsh was unaware of, and would be very surprised by any plans to remove Herefordshire's A&E service, as part of the Sustainability and Transformation Plans.

·       Access to care information, to assist ambulance staff care for patients was something being looked at by WMASFT, which would be very helpful.

·       Ambulances were not serviced in conjunction with fire engines because of the specialist needs involved.

·       HOSC members shared concerns about hospital handovers, and Dr Marsh pointed out that problems occurred at a minority of hospitals, and were resolvable.

·       HOSC members praised the Community First Responder Schemes and Cllr Hill would provide further details of potential interest from Redditch students to participate in training.

·       The Chairman of Worcestershire Healthwatch was invited to comment and advised that very few complaints were received about WMASFT. The past few weeks had stretched everyone and it was important to work together.

·       The Healthwatch Chairman suggested that demand from elderly residents at residential and sheltered housing was an area for work. Dr Marsh agreed that 999 calls often came from relatively junior staff and that the role of GPs may have potential to help, through regular dialogue and a more proactive streamlined process.

·       The roles of 111 (the NHS non-emergency number) and GPs was acknowledged, since delays in response or unavailability of appointments may prompt people to go to emergency services.

·       Cllr Hill believed that some Redditch residents used the Alexandra Hospital's A&E as they feared losing the service if it was underused.

·       The long-term viability and staffing of two A&E centres for Worcestershire was raised, however whilst acknowledging the problems, Dr Marsh stressed the need to resolve hospital handovers, rather than mask over the problem. The current fragility of the two A&E centres did not lend itself to such a move. 

The HOSC Chairman thanked all WMASFT staff, and everyone present for a constructive and honest debate. Many of the areas discussed would prove useful in the Committee's future discussions.

The offer to visit the WMASFT headquarters would be facilitated.