Agenda item

In attendance for this item were:

Dr Anthony Marsh, Chief Executive

Mark Docherty, Executive Nurse and Director of Clinical Commissioning and Service Development

The Health Overview and Scrutiny Committee (HOSC) had requested an update from West Midlands Ambulance Service (WMAS) NHS Foundation Trust. A presentation had been circulated to HOSC members before the meeting (available on the website), and the Chief Executive and Executive Nurse highlighted the key points. The information provided included  details of the Service's history, WMAS's vision, strategic objectives and priorities, an overview of progress and plans for 2017/18, Winter preparations, activity, hospital handover delays, NHS 111, response times, challenges, reference costs, workforce, work with care homes and on births, clinical and quality indicators, WMAS sites and community response schemes.

Headlines included achievement of all new targets and WMAS' award of  ambulance service of the year. 98% of front line ambulances had a Paramedic on board, which was the highest skill mix in the country. WMAS was the only ambulance trust with an outstanding rating from the Care Quality Commission. The Service had the highest non-conveyance rate (45%) and had achieved 100% roll-out of electronic patient records.

The Winter period had been challenging but Dr Marsh believed the NHS was much better prepared than previously, which had avoided even worse outcomes.  The additional Government funding announced in Autumn had allocated a small amount to WMAS, which it had used to improve hospital discharge. Already it was important to capture learning and plan for next Winter.

Dr Marsh had roles in several other national forums, for example the Joint Emergency Service Interoperability Programme, the National Ambulance Resilience Unit and the national response unit for countering terrorism.

Activity continued to be above the contracted level and growth this year had been unprecedented, with very steep increases in activity during the recent adverse weather in March; 5 March had been the busiest period so far this year with over 5000 999 calls over a 24hour period. Annual increases of around 4% were predicted to continue. WMAS received payment for increased activity, and could deal with these increases; its biggest challenge was coping with hospital handovers, which were rapidly getting worse.

Of the 23 hospitals worked with, most coped well but 5 caused big concerns, perhaps because they were large hospitals.  However Worcestershire Royal Hospital (WRH) caused most concern, which was not a particularly big hospital. WMAS had written to WRH 3 years previously to express concern, however handovers were now much worse, and it was felt, were reaching the point of compromising patient safety.

WMAS presented data to indicate that performance of the NHS111 contract was significantly poorer than in previous years. For example, during the previous month only 65% of calls had been answered in 60 seconds, against the target of 85%. If callers gave up and went elsewhere – such as to A&E or dialling 999 - this could generate unnecessary work for the health service.

WMAS was the only ambulance service to achieve all new response targets, which were outlined to HOSC members.  New targets had been introduced following a review which WMAS had been involved in.

WMAS had one of the lowest conveyance rates to A&E, which was contributed to by the paramedic presence, the benefit of which would continue to increase as their experience and competence grew.

Regarding current challenges, hospital reconfigurations created additional pressure throughout the region and while WMAS supported the clinical evidence behind reconfigurations, and was provided with additional funding for longer journeys, it was important to ensure that this did not harm patients.

WMAS was the best performing service in the country, despite having one of the lowest reference costs; important factors included a stable executive team, strong decision making, and support for staff.

The Chief Clinical Nurse spoke about the WMAS's work to encourage care homes to use NHS111 or the patient's GP, rather than 999, in order to avoid unnecessary hospital visits, since the environment of a care home was more appropriate in many cases. However 999 should be used if the patient was unresponsive. Greater take up of these concepts would be very beneficial.

Work on births, including appointment of a Midwifery lead post, was bringing improvements to what was a high risk part of the Service's work.

Dr Marsh praised community response schemes and encouraged HOSC members to get involved in local initiatives to facilitate more defibrillators in places with good public access.

The Chairman invited questions and the following main points were discussed:

·         HOSC members were very impressed with the information presented and WMAS's performance, staff and leadership, which they saw as an exemplar for other NHS services.

·         Regarding mechanisms for ensuring long-term good operational practice in the NHS, HOSC members were advised that a review of NHS efficiency was being led by Lord Carter and any ideas for ambulance services would be embraced.

·         When asked whether ambulance services picked up shortfalls in other NHS provision, in particular primary care, the WMAS representatives believed this was the case.

·         It was confirmed that handover delays and lost hours undoubtedly impacted on WMAS capacity and its ability to respond to patients elsewhere, and data for WRH and the Alexandra hospital in Redditch (The Alex) showing lost hours, and breakdown of handover delays were highlighted to the Committee.

·         HOSC members expressed concern about reported performance issues with NHS11.  The Chief Nurse advised that the contract, commissioned by clinical commissioning groups, had been run by WMAS until 2014/15.    WMAS had chosen not to tender for the latest contract because it did not have confidence in the specification.

·         A member referred to incidences brought to her attention where it was suggested that mothers due to give birth had been transported long distances without their partners because of lack of available beds at WRH.  The WMAS representatives agreed this very unfortunate as such journeys were very difficult.

·         Further details on work with care homes were provided, which focused on encouraging a uniform system on respect forms – which recorded details of residents' preferred place for end of life care. This information was important, since ambulance crews would not know the patient and could only act on the information given to them at the scene.

·         A HOSC member pointed out that medical care at care homes would be more consistent if residents were encouraged to register with the local GP, which Dr Marsh agreed with and tried to promote.

·         WMAS's approach to staff training was welcomed.

·         HOSC members asked about data on lives saved through defibrillators and their use per parish? It was confirmed that there was very strong evidence that defibrillators saved lives and WMAS was very pleased about its successful application to be a vanguard to work with the British Heart Foundation, which included research on generating a regional database and ensuring defibrillators were in the best and most 24 hour accessible places – expansion of the use of defibrillators was welcomed by HOSC and was to be encouraged.

·         The HOSC Chairman, who was also the Vice-Chairman of Hereford and Worcester Fire and Rescue Service, asked whether WMAS had a policy for working with other services, which could benefit more rural areas and save money?  Dr Marsh advised that where ambulance services had relied on others, it had not been found to be any more effective or add value. Additionally, as a high performing service, WMAS had a very specific way of operating ambulances. 

Hospital handover delays/Winter pressures

The HOSC returned its focus to the issue of hospital handover delays highlighted in the presentation, and the Vice-Chair queried why Worcestershire Acute Hospitals Trust (WAHT) appeared not to listen to repeated concerns raised by WMAS; why was this and what were the solutions?

Dr Marsh said that difficulties could be resolved, which was demonstrated by hospitals in Birmingham and Stoke which had turned around problems with delayed handovers. There was in fact daily dialogue with WAHT but for some reason issues were not resolved and handover performance had deteriorated.

Central to WMAS concerns was that whereas patients were probably safe being cared for in a hospital corridor or even outside, those from other 999 calls which queueing ambulances could not attend to, were not safe. WMAS was already helping discharge patients much more quickly from both WRH and The Alex, and diverted patients to The Alex to help with pressure at WRH. There were fears for patient safety and the situation could simply not carry on like this – action was needed from the hospitals, CCGs and the regulators.

HOSC members reflected on the recent presentation from WAHT Chief Executive which had included winter pressures but also early indications of improvement. When asked what was their view on the root cause of the hospital blockages, the WMAS highlighted leadership, grip, owning your problems and decision making. The need for highly visible timely performance monitoring was also referred to. The Chief Executive claimed that WMAS was not perfect but did make necessary, sometimes difficult, decisions..

Representatives from WAHT were present and were given the opportunity to comment on the issues of hospital handovers.

Mags Shaughnessy (Deputy Director of Operations) thanked WMAS for its comments and said that convincing the Committee that safety was the Trust's prime concern was paramount. Delayed handovers which took ambulance crews away from calls, were regrettable and WAHT was very grateful for WMAS help and did want to improve, however it was important to note that its staff were working incredibly hard, under immense pressure.

The WAHT representative pointed out the difficulties around Worcestershire's older age profile which required more complex care. WAHT had been trying to use its frailty service better although effectiveness had been hindered by numbers. WRH was aware of its problems with staffing and heavy reliance on agency staff and was working to try and attract staff. There were also insufficient bed numbers. The HOSC was aware of building plans and work would start on the bridge in the Summer which would be a part of work to prepare for next Winter. Patient flow needed to improve which would also involve looking at the older age profile and support in the community. Issues were reviewed each day, since Christmas using a command and control model, and WRH worked with The Alex to try and balance the stresses of each day. The new Chief Executive, Michelle McKay had a very different approach and was determined to fix the problems.

The Chairman had had sight of two letters in which WMAS had flagged up concerns to WAHT's Chief Executive about increasing delays with hospital handovers.  The Chairman had been advised that the letters could be circulated to HOSC members, and would be after the meeting. He referred to an extract where WMAS Executive Nurse highlighted that the previous evening (16 February), over 10 ambulances had been waiting to take patients in to the hospital, some of which had been waiting nearly 3 hours. He also said that WMAS were ready to deploy field hospitals (tents) outside the hospital, if they were unable to take patients into the hospital for a timely handover.

Dr Marsh pointed out that responses to the letters had not been received, although it was pointed out by WAHT's Director of Communications that a meeting  had taken place with WMAS to discuss the issues raised in the letters.

HOSC members agreed that the issue of hospital handovers was a serious concern which would need to be put to WAHT's Chief Executive at a future meeting.

A member expressed concern and sympathy that systems appeared at breaking point,  that it would be a massive job to turn the situation around, and to let members know if they could help.  Another member voiced concern about potential impact on the medical outcome of patients kept waiting and suggested that WMAS staff were effectively staffing the hospital.

Dr Marsh acknowledged these concerns but pointed out that WMAS was one of the lowest funded ambulance services in the country.

Cllr Rayner, as lead HOSC member for WMAS for several years, gave feedback on her attendance at board meetings and conversations with staff representatives.  In her view leadership was very strong and learned from staff at all levels; others could learn from their techniques.

HOSC agreed that further scrutiny would be required on ambulance hospital handovers and the Chairman undertook to write to the Acute Trust to clarify its response to WMAS' February letters. HOSC would also request further information from Worcestershire's clinical commissioning groups on performance of the NHS111 contract and on bed capacity in acute settings.