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Sirens in sync

Sirens in sync
22 April 2016

Commissioners and the ambulance network have been working together to improve ambulance services to fall in line with the Five Year Forward View

Commissioners and the ambulance network have been working together to improve ambulance services to fall in line with the Five Year Forward View

Last November NHS Clinical Commissioners (NHS CC) and the National Ambulance Commissioners Network (NACN) launched a discussion paper Developing an ambulance commissioning strategy: Five Year Forward View and beyond (see Resources). This article provides a summary of key points and recommendations raised in that paper, some of which there have already been positive developments on since the paper’s publication.
The paper recognises that, as with many parts of the NHS, the current system in which ambulance services work was not designed to meet the needs of today’s population. Changes need to be made at pace to ensure the system remains sustainable going forward while giving patients the best care. The paper aims to progress the debate and inspire discussion through setting out how ambulance services work within the current system, what, as commissioners, we believe the future could look like, and the challenges that need to be overcome for this to happen.

The current context of ambulance commissioning
There are 11 ambulance trusts in England and while clinical commissioning groups (CCGs) are responsible for commissioning their services, this is based on a collaborative commissioning model, negotiated on a regional basis by a lead CCG.
Both commissioners and providers acknowledge that the current model of ambulance service provision and commissioning is not designed to meet the needs of today’s population. Health and care systems cannot afford the continued year-on-year increases in activity, and so the way the service is provided and commissioned needs to change, to achieve sustainability and to improve patients’ experiences and outcomes. These changes must ensure that those most in need are reached fast, and that everyone receives the right care, in the right place at the right time.
The Five Year Forward View sets out the need for transformation across healthcare over the next five years and beyond. A significant element of this is around care being delivered locally, but with some services in specialist centres. Both of these ambitions have an impact on an ambulance trust whose organisational form is to deliver care across a large geographical area.
While the Forward View sets out a clear direction for the NHS, the Urgent and Emergency Care Review (UEC Review) is more significant for the ambulance service. This sets out a vision for a future system that is safer, sustainable and capable of delivering care closer to home, helping to avoid journeys to hospital unless clinically appropriate. In order to achieve the aim of patients receiving care closer to home, staff need to be trained and empowered to support decision-making to enable patients to be treated appropriately out of hospital or to make referrals in a flexible way.
Since the publication of the UEC Review vanguard sites have been identified relating to urgent and emergency care to support the document’s key objectives – these have provided opportunity for the ambulance service to be engaged in shaping future service provision. The ambulance service is an integral part of the health and care system and opportunities exist within the proposed new models of care for it to be part of the system solution.

What needs to happen to ensure an ambulance service fit for the future?
Below we set out the key changes that need to be made to the way in which the system works to ensure our ambulance service is fit for the future.

Within the 999 service, the majority of trusts have two minutes to undertake a clinical triage, before determining the most appropriate level of response, and staff within the NHS 111 service have on average up to nine minutes to do this.
It is of course right that critically ill patients should be identified quickly with a corresponding fast response. For other patients there should be a consistent and comprehensive clinical triage enabling the most clinically appropriate response – achieving this may lead to an increased triage time. We would like to work with the Association of Ambulance Chief Executives (AACE), in conjunction with NHS England, to determine what the appropriate time should be.

Response model and measuring success
Standards are important to patients and the public, and play a crucial role in reducing variation across the system and improving outcomes for people. However, there is a danger that where only time-based targets matter this can lead to a response model that does not align to clinical need or outcomes and in fact creates perverse behaviour, such as multiple vehicles being dispatched to a single incident, often to be ‘stood down’ before arrival.
It is absolutely correct to ensure that critically ill patients receive a rapid response, but this is not necessarily appropriate for all conditions. There needs to be a shift away from the current conveyance model, and instead development of a range of system-wide outcome-based measures that build on the current Ambulance Quality Indicators (AQIs). Ways of measurement could include clinical outcomes from treatment and patient experience of treatment in non-acute settings.
It is critical that in its development, commissioners work with providers and engage with patients to determine the most appropriate clinical response model.

Referral rights to community and primary care
Access to a wide range of clinical advice is critical to support the reduction in conveyance to emergency departments and ensure the patient gets the best possible care. To facilitate this, ambulance services need unrestricted referral rights to community and primary care services any time of the day, to support delivery of increased levels of hear and treat, hear, treat and refer and see and treat, leading to savings across the system.

Transport model
As part of the move to implement the ambitions around urgent and emergency care, it is proposed that centres will be developed with the very best expertise and facilities to maximise the chances of survival and a good recovery
Discussions around the development of these specialised centres must include ambulance providers and commissioners
at the early stages to understand the impact on resources, with ambulances potentially required to travel further distances, taking them out of their normal locations. With the evolving care models and the drive for more care to be delivered closer to home, there is also need to review the two tiers of ambulance transport currently provided – urgent and emergency and patient transport service. We would suggest that these could be developed into three tiers:

  • Planned – for patients requiring transport on a planned basis, as part of their ongoing treatment needs, but do not require the staff to have clinical skills.
  • Unplanned – for patients with critical, serious or life-threatening emergency
  • care needs who require a highly skilled crew.
  • Enhanced patient transport service (PTS) – for patients currently classified as ‘urgent’ who require transport to hospital with the support of staff educated to a designated level. Currently this group is usually ‘booked’ between midday and late afternoon following assessment by a GP or other healthcare professional.

What is needed to support these changes?
There are a series of key enablers required to support change to the system we want to create – one that incentivises a whole-system approach to increasing safe care closer to home, sharing risk across providers and commissioners alike.
These relate to workforce, information technology, payment mechanism and commissioning models.

The ambulance service is facing significant challenges in the recruitment and retention of trained paramedics. Not only is there a shortage but the training and roles available do not always support a focus on more community-based care to support the patient to remain at home where clinically safe and appropriate to do so.
Health Education England (HEE) with AACE and the College of Paramedics have undertaken a Paramedic Evidence Based Education Project (PEEP) that looks at the need for changes to paramedic training, together with a review of skill mix in the overall workforce. Due to the high demand across the urgent care system for paramedics and the rate of leavers from the service, we believe that HEE should consider increasing training places across the country and map out with commissioners and providers the future requirements and geographical areas of deficit, so that a realistic plan and timescales can be agreed.
We also need to look at the way in which we use staff, making greater use of those staff with advanced skills to focus these across specific elements of care, such as community or emergency needs, rather than all staff focussing on all conditions. This would support a greater level of multi-disciplinary working.

Information technology
To support the patient journey, ambulance staff must have access to the correct information including patient records. To provide the appropriate care, they need easy access to the local directory of service and for staff to use electronic patient care records so that all clinicians involved in a patient’s care can access the relevant information.

Payment mechanism
Traditional transactional and competitive behaviours between providers and commissioners, will not deliver the ambitions contained in the UEC Review. The current tariff is too sensitive to changes that impact on overall costs, resulting in risks to both the provider and commissioner. There needs to be recognition of the costs of delivering a 24/7 response model in both an urban and rural area with the payment mechanism reflecting this. Commissioners believe that unless the payment mechanism supports transition of fixed costs to other community and primary care settings then the transformation required will not happen.

Commissioning models
The majority of contracts for emergency ambulance provision are negotiated on a regional basis by a lead CCG under collaborative commissioning arrangements.
There are some areas where we believe national commissioning is more appropriate for ambulance service provision – that required to support national resilience, particularly with regard to specialist functions covered by the emergency preparedness response and recovery (EPRR) core standards, for example the hazardous area response team (HART).
In other matters, we believe that the collaborative commissioning arrangements remains the appropriate model of commissioning. With the evolution of increased examples of integrated care models and new commissioning models, commissioners will need to continue to collaborate across larger footprints to ensure resources are maximised efficiently and deliver services differently.
While the model of commissioning is appropriate, we would again reinforce the point that we need to change to commissioning for outcomes. There must be a move from the current contracts for services, to commissioning for outcomes focused around patient and clinician experience and patient outcomes.

Collaborating to provide a modern ambulance service
The report set out to progress the debate and inspire discussion, and since its launch we have used it to engage with stakeholders across the system. Since publication we have already seen a number of welcome developments with regards to testing increased triage times, the review of current call codes and progress of urgent care vanguards that includes ambulance services. We look forward to collaborating further with partners on these and other developments.
It is only through this collaboration across the healthcare system that we will achieve our aim of moving swiftly to provide the public with a modern fit-for-purpose service where sickest are reached fast, and that everyone receives the right care, in the right place at the right time. The UEC Review has given us an opportunity to seize the moment and reform the ambulance service for the better – it is crucial that we do not lose it. l

Jane Hawkard, chair of NHS Clinical Commissioners National Ambulance Commissioners Network and chief officer of NHS East Riding of Yorkshire Clinical Commissioning Group.

Developing an ambulance commissioning strategy: Five Year Forward View and beyond –

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