HEALTH OVERVIEW AND SCRUTINY COMMITTEE

23 September 2021

South East Coast Ambulance Service Update

Report from: Bethan Eaton-Haskins, Executive Director of Nursing and Quality, SECAmb

Author: Ray Savage, Strategic Partnerships Manager (SECAmb)

Summary

This report follows the update in November 2020 and further updates to the committee on the South East Coast Ambulance Service NHS Foundation Trust’s mobilisation of the NHS 111 contract, including the establishment of the Clinical Assessment Service (CAS) and the development of 111 First. The key areas included are go-live of the NHS 111 contract, establishment of 111 First and Direct Access Bookings, operational performance and recovery, the impact of COVID-19 and the development of the new SECAmb NHS 111 Operations Centre in Medway.

1. Background

1.1. In 2012, South East Coast Ambulance Service NHS FT (SECAmb) and Care UK (formerly Harmoni) were awarded the contract to provide NHS 111 services across Kent & Medway, Surrey, and Sussex (excluding East Kent).

1.2. At the end of the 5-year contract period in March 2019, Surrey commissioners procured a new provision with Care UK (now Practice Plus Group) specifically to focus on the Surrey Heartlands geographical area, with a contract start date of the 1^st April 2017 (extended twice). East Kent also started a new provision with Nestor Primecare Services Ltd (Primecare) on the 1^st September 2016, however, Primecare’s decision to end the contract prematurely in December 2017 saw the transfer of the NHS 111-service provision to the not-for-profit social enterprise - Integrated Care 24 Ltd (IC24). Both these procurements followed a competitive tendering process.

1.3. The Kent & Medway, and Sussex (KMS) commissioners advised both SECAmb and IC24 that a joint county procurement would take place with one provider delivering the NHS 111 service across Kent & Medway and Sussex from the 1^st April 2020 however, the start date of the new contract was delayed by 6 months until the 1^st October 2020.

1.4. This delay of 6 months which was primarily attributable to the COVID-19 pandemic, would enable the Kent & Medway, and Sussex commissioners to incorporate in the new NHS 111-service a Clinical Assessment Service (CAS) as outlined in the Urgent and Emergency Care Route Map (November 2015). It was also recognised that the NHS 111 service, going forward, would be a key system partner in the delivery of the Integrated Urgent Care programme, of which the Clinical Assessment Service would be a key element, therefore an interim arrangement was put in place with both SECAmb and IC24 continuing to deliver their respective NHS 111 services.

1.5. On the 12^th July 2019, following a competitive procurement process, SECAmb was confirmed as the preferred bidder for the Kent & Medway, and Sussex (KMS) NHS 111 CAS service.

1.6. The new five-year contract, awarded in August 2019 by NHS commissioners across Kent & Medway, and Sussex, was valued at £90.5m. SECAmb and IC24 had previously provided NHS 111 to parts of Kent and Medway, Sussex, and Surrey but would now work in a joined-up way.

1.7. The significant impact of the COVID-19 pandemic and the uncertainty it caused further delayed the go-live by 6 months and the contract was finally mobilised on the 1^st October 2020.

Since the last update to the HOSC in November 2020, the Trust has:

o continued to respond to the COVID-19 pandemic

o mobilised the NHS 111 Integrated Urgent Care (IUC) CAS

o delivered the NHS 111 First programme, which was launched across the region, via a pilot, in Medway on the 16^th September 2020, and subsequently implemented across Kent & Medway, and Sussex by the end of November 2020, aligned to the national roll out - timelines and milestones put in place by NHS England

o East Sussex Health Care NHS Trust (ESHT) was the first site in Sussex to go live

o SECAmb worked collaboratively with commissioners to implement the digital ‘interoperability road map’ across the region

1.8. COVID-19 brought significant challenges in the period prior to the ‘go-live’ of the new NHS 111 CAS contract, with levels of activity not experienced before by an NHS 111 provider, delayed the mobilisation by 6 months, and has continued to challenge the delivery of the 111 service with sustained higher than planned levels of activity to date.

1.9. These increased activity levels have affected all NHS 111 providers across England.

1.10. South East Coast Ambulance Service NHS FT (SECAmb) is the only 111 CAS to go-live nationally since the 1^st January 2020.

2. Service Mobilisation

2.1. Prior to the award of the KMS NHS 111 CAS contract, SECAmb had already been increasing the number of clinical staff in its 111 operations centre as well as broadening the clinical expertise available to support the health advisors, either when a patient required a clinical call back due to complex medical conditions or when an NHS pathways disposition required a clinical validation. The CAS would also provide clinical support to a Health Advisor (HA) during a call if required.

2.2. Following the announcement of the award, the Trust, working with its sub-contractor, IC24, started to plan the integration of the two services to form a single NHS 111 CAS service across Kent & Medway, and Sussex.

2.3. The key areas of focus for the integration of the two legacy and incumbent services (SECAmb/IC24) were:

· Digital interoperability, including telephony systems, compatible digital hardware, network connectivity and system testing to ensure that all clinical risk management standards would be met etc.

· IC24 staff training on the SECAmb ‘Computer Aided Dispatch’ system (Cleric)

· Robust governance frameworks in place and understood

· Resilience and contingency plans in place

· Implementation of a full Electronic Prescribing Service (EPS), incorporating First of Type (FoT) with NHS Digital for the Cleric Computer Aided Dispatch (CAD)

· Creation of a fully integrated CAS, with a clinical multi-disciplinary team to oversee patient flow across the integrated urgent and emergency care system, with a focus on mitigating the risk to other emergency care services and providers with effective, clinical intervention

· Delivery of Direct Appointment Booking (DAB) to ensure that patient flow through the healthcare system is managed more effectively, reduced unheralded demand and addressing healthcare service provider capacity inequalities across the region

2.4. Service delivery is from 4 key sites:

· SECAmb’s existing site in Ashford

· IC24’s existing site in Ashford

· SECAmb’s East Emergency Operations Centre in Coxheath

· SECAmb’s West Emergency Operations Centre in Crawley

2.5. A recruitment programme commenced due to the additional workforce required. This included both health advisors (HA) and clinical staff for the CAS.

2.6. Complimentary rotas for both SECAmb and IC24 staff were established to ensure that rota profiling matched expected demand, following a clinical skill-mapping exercise to ascertain which clinicians would be needed at what times to ensure apposite clinical care.

2.7. On the 1^st October 2020 at 11:00, the switch over from the two independent service providers took place into the one service provision.

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3. 111 Clinical Assessment Service (CAS)

3.1. The NHS 111 CAS was a key part of NHS England’s transformation of NHS 111 into a key partner in the delivery of the Integrated Urgent Care (IUC) programme.

3.2. NHS 111 is available 24/7 and is free for the caller either via a mobile or a landline and can also be accessed online via www.111.nhs.uk.

3.3. Prior to the development of the 111 CAS, NHS 111 would receive calls from the general public via the 111 number and the calls would be answered by a Health Advisor (HA).

3.4. The HA would use the NHSE, Clinical Decision Support System (CDSS), NHS Pathways, to reach a disposition (outcome) and linking in with the Directory of Services (DoS), would present a number of appropriate endpoints for signposting the caller to. This is unless an emergency response was needed, a clinical call back was required, or the call could be closed without the need for onward referral. The system used by SECAmb in both its 999 and 111 services, is NHS Pathways.

3.5. NHS Pathways is the NHS E preferred CDSS tool for 111 services and is the only one that directly links to the DoS.

3.6. NHS Pathways telephone triage system is also used across England in the following settings:

· NHS 111

· 999

· Integrated Urgent Care Clinical Assessment Services

· NHS 111 Online

· Reception points in emergency departments

3.7. NHS Pathways is a Department of Health and Social Care owned tool, commissioned by NHS England and delivered by NHS Digital.

3.8. NHS Pathways principally works through a series of algorithms that link to clinical questions. Each time the HA asks a question and enters the response, the algorithm will then present new questions until a disposition is reached. It is important to note that life-threating questions are asked early in the process to ensure that an urgent or emergency disposition is reached quickly, e.g., when an ambulance response is required.

3.9. When the disposition is for an emergency response by an ambulance, the patient details are immediately electronically transferred to the trust’s 999 emergency operations centre and appear on the ambulance dispatcher’s screen.

3.10. The transformation from the original NHS 111 service into the NHS 111 IUC CAS, significantly increases the level and breadth of clinical support available to the HA. The clinician in the CAS will speak directly with the patient either whilst still connected, or when completing a clinical call back.

3.11. Certain dispositions may automatically result in a caller being advised that a clinician in the CAS will call them back to discuss their presenting condition. Also, many ED (as per NHS E 111 First criteria) and all ambulance category 3 and 4 NHS Pathway dispositions will be transferred to the ‘clinical queue’ (a virtual list of calls requiring clinical input), which is monitored 24/7 by clinical safety navigators and supported by 24/7 GP oversight. This is to ensure that calls are appropriately risk assessed and managed to meet clinical need and call back timeframes.

3.12. Prior to the award of the KMS 111 CAS contract, SECAmb had already been in the process of broadening the range of clinical specialists and developing a multi-disciplinary team in both its NHS 111 Operations and 999 Emergency Operations Centres and therefore, was in a good position to build on award of the contract.

3.13. The level of clinical expertise and support now available through the CAS includes:

· Dental nurses

· Mental health practitioners

· Advanced clinical practitioners (e.g., an Advanced Nurse Practitioner)

· Paramedics and specialist paramedics

· Midwives

· Pharmacists

· General practitioners

· Urgent care practitioners

· Paediatric nurses

· Palliative care nurses

· Registered general nurses

3.14. Through this expansion of the CAS, NHS 111 is able to accept more dispositions, and this has been evidenced in the number of patients referred to the CAS. Prior to the formal launch of the CAS in October 2020, an average of 28,000 per month were being referred to the CAS, and since October 2020 this average has increased to 42,000 referrals per month (see Appendix A).

3.15. NHS 111 has now been established as a key first point of contact for clinical advice/guidance not only for patients but also health care professionals, in the delivery of integrated urgent and emergency care.

3.16. SECAmb has continued to integrate both its 111 and 999 operations and has a dedicated management team who provide clinical and operational oversight for both, creating resilience and robustness in the delivery of the service, in addition to enabling the sharing of best practice, which has been made possible digitally through a single computer platform.

3.17. The ‘Cleric’, Computer Aided Dispatch (CAD) computer system is used across both 111 and 999 as well as being installed in the IC24 contact centre to provide a seamless digital platform for service delivery, along with enabling several SECAmb staff to be dual trained in the answering of both 111 and 999 calls, therefore enhancing the resilience of both services.

3.18. SECAmb has also undertaken several pilots in its 111 CAS during the COVID-19 pandemic to improve patient accessibility to senior clinicians and to enhance patient care. These include the 2020 NHS England National Paediatric Consultant pilot, which saw paediatric specialists working as part of the SECAmb 111 CAS, leading the care for children accessing 111 and the use of Video Consultation (VC) technology to enable patients’ access to GP’s, particularly beneficial during the COVID-19 pandemic lockdowns.

3.19. The introduction of the Kent & Medway Care Record (KMCR) has given NHS 111 IUC CAS clinicians access to patient records to support patient assessment and clinical decision making. Sussex is continuing on developing its patient record sharing platform.

3.20. Following 18 months of collaboration, working with NHS England, NHS Digital, Commissioners, and the Computer Aided Dispatch system provider – Cleric, SECAmb was the first ambulance service in England to implement an Electronic Prescribing Service (EPS) in its own CAD during May 2021. EPS is an integral part of the CAS and enables other clinicians like Advanced Nurse Practitioners, Urgent Care Practitioners, Pharmacists as well as the General Practitioners (GPs) working in the CAS to generate prescriptions and electronically send them to a dispenser (such as a pharmacy) near to the patient.

3.21. During July 2021, the NHS 111 IUC CAS went live with the Pathways Clinical Consultation Support (PaCCS) tool, further enabling clinicians to remotely consult with patients during a clinical call-back as well as enabling the referring of patients into new pathways, e.g., Same Day Emergency Care (SDEC).

4. NHS 111 First

4.1. NHS 111 First was a national initiative by NHS England to reduce the unheralded (walk-in) activity that would have traditionally self-presented at an acute hospital’s emergency department (ED). This is achieved through a patient contacting NHS 111 in the first instance and following a telephone triage, a disposition (outcome) would be reached. This could result in an ambulance being dispatched or an appointment/arrival time offered at an appropriate end point.

4.2. NHS England’s ambition was to have NHS 111 First in place by the 1st December 2020 as a response to public behaviour during the first wave of the pandemic when attendances at emergency departments reduced significantly and call volumes into NHS 111 dramatically increased as patients sought urgent medical advice from alternative sources.

4.3. SECAmb, along with system partners and commissioners, set about achieving this through a programme of digital interoperability where appointment slots/arrival times are made available to NHS 111 with the appropriate end point having the capability to generate an appointment slot and receive an electronically transmitted Direct Appointment Booking (DAB).

4.4. Across Kent & Medway, and Sussex, Medway was the first system to go-live with NHS 111 First across Kent & Medway, with a soft launch on the 16th September 2020. In Sussex, the first acute trust to go-live was the East Sussex Healthcare NHS Trust.

4.5. The development of NHS 111 First was not to be limited to booking appointment slots for EDs and therefore highlights other appropriate end points earlier, e.g., GP surgeries, Urgent Treatment Centres, Same Day Emergency Care (SDEC), surgical assessment units, community frailty teams etc.

4.6. Despite the challenges of linking the different providers digital systems, NHS 111 First DAB was fully implemented across Kent & Medway, and Sussex during December 2020.

5. Directory of Services

5.1. The Directory of Services (DoS) is a central directory that is integrated with NHS Pathways providing real time information on available services to support clinicians and HAs in NHS 111 and emergency medical advisors in 999 and patients (via NHS 111 online).

5.2. The DoS is automatically accessed when NHS pathways reaches a non-emergency disposition and will give the HA a list of end points/pathways to refer the caller into, in a priority order, with the most appropriate service available as the first option.

5.4. The interoperability between NHS Pathways and the DoS requires a patient’s condition(s) to be entered only once and avoids the patient being asked several times to repeat the same information.

5.5. The clinical commissioning groups have dedicated DoS leads whose primary responsibility is to maintain the profiles on the DoS, liaise with end users and ensure any amendments are made in a timely manner due to the DoS being a live directory. The DoS leads are supported by a regional DoS lead who liaises with NHS Digital on a regular basis.

6. Performance

6.1. SECAmb’s NHS 111 service has been on a significant journey prior to, during and post mobilisation of the new contract, transitioning from a traditional NHS 111 service to a full, complex and integrated CAS with several interoperability challenges as well as the NHS England/Digital initiatives this entails.

6.2. The NHS 111 IUC CAS was the only mobilisation to have taken place during the COVID-19 pandemic, working through the volatility in activity, changes in patient behaviours and service provision across the system, and staffing levels that the pandemic brought.

6.3. The service had experienced unprecedented levels of activity during February 2020, followed by a decrease in March, however, there has subsequently been a steady increase of activity through the summer. This trend continued into the autumn and winter with the service activating the national contingency on a regular basis during December and January (2021) due to a combination of increased call activity linked to the implementation of NHS 111 First and short-term staffing abstraction issues, predominantly COVID-19 related to infection outbreaks in the Trust’s contact centres.

6.4. During October 2020, the number of ‘calls offered’ was 105,146 and overall has continued to increase to a figure of 138,884 in July 2021. February 2021 was the only month when the number of calls fell below the October level with circa 89,000 calls (see Appendix B).

6.5. These pressures have continued throughout 2021, with activity continuing to significantly exceed the originally forecast/commissioned levels. This has resulted in working with KMS commissioners to agree funding for increased staffing levels to meet the ‘new’ demand.

6.6. Some of the key contributing factors for the continuing high levels of activity are:

· The COVID-19 pandemic and patients not having accessed health services during the periods of lockdown

· Illnesses usually seen during the winter period continuing into the summer months

· Callers expressing difficulty in accessing Primary Care or being redirected to NHS 111 from Primary Care providers

· Communication promoting NHS 111 as the first point of contact for urgent medical advice.

6.7. The service has also experienced rapidly changing demand profiles with a clear increase in activity prior to the traditional 18:00, Monday to Friday, call levels. This change in demand required a significant review of the existing rotas for HAs and CAS clinicians and continues to be monitored in conjunction with the ongoing recruitment campaign for all staffing groups.

6.8. The ongoing recruitment programme is meeting the required contracted staffing levels for both health advisors and clinicians for the CAS based on the agreed forecast levels of demand however, current demand is routinely in excess of the activity levels currently funded.

6.9. The time it takes to answer a call is the ‘service level’ and as the call volume continued to increase, inevitability the time taken to answer a call has become challenged. During the past 10 months, the service level has ranged from 90% call answering in 60 seconds at the beginning of March 2021 to 19.7% in July 2021 (see Appendix C).

6.10. The service also saw a deterioration in call abandonment performance. The abandonment rate after 30 seconds for quarter 1 (April, May, June 2021) was 13% against a target of 5%. This was discouraging when compared to quarter 3 of 2020 with an abandonment rate of 6.67%. As with the service level, the extenuating circumstances within which the NHS 111 service is operating must be taken into consideration. This deterioration in both call answering responsiveness and abandoned call rates is reflected across all 111 providers nationally.

6.11. Performance in the NHS 111 IUC CAS for clinical contact rate has been consistently above the national average, with the past 3.5 months achieving over 148,000 cases being directed into the CAS. For quarter 1, the KMS NHS 111 service achieved a clinical contact rate of 46% compared to a national achievement of 41% (see Appendix A/D).

6.12. NHS 111 ambulance referral rates have continued to be strong and have delivered below the national rate, underpinned by SECAmb consistently achieving a referral rate to 999 of c9%, with an average of 92% validation of all C3 and C4 dispositions resulting in c62% of incidents being downgraded to an alternative outcome (see Appendix E).

6.13. When a disposition is reached for an emergency treatment centre, cases are clinically reviewed and during July 2021 55.5% of these cases were diverted to alternative providers.

6.14. SECAmb’s ED referral rate has been consistent at c9% and again, this is below the national average with SECAmb being the 4^th best performer amongst NHS 111 providers (see Appendix F).

6.15. During the first 6 months of the CAS being operational, 49.5% of ED dispositions, following validation, were signposted to a non-ED service.

6.16. The Trust has continued to work closely with commissioners and NHS England (NHS E) since the launch of the CAS and NHS 111 First programme, as these services have developed further.

6.17. NHS 111 First DAB continues to be successful with SECAmb continuing to book more appointment slots/arrival times than most other 111 services. March 2020 saw c300 direct appointments made. May, June, July and August saw an average of 26,280 (27%) of all patients triaged by 111 receiving a DAB. The direct benefit of this is to support system partners in managing capacity by converting unheralded activity into heralded activity (see Appendix G).

7. Staff Engagement

7.1. Staff within the 111-operating environment have been constantly working under pressure with the continuing high levels of activity, programme mobilisation, launch of 111 First, COVID-19 related absences, and the ongoing recruitment campaign.

7.2. Staff wellbeing has been a priority with a continued focus on facilitating support while at work and also through services available outside of the workplace. Some of the key initiatives in place are:

· Desk top fans

· Agile working provision

· Roll-out of staff uniform

· A wellbeing room for staff to relax

· Access to the senior leadership team

· Weekly Q n A forum for all staff to access via “Ask111leaders”

· Coloured identification lanyards

· Updated eating areas, including outside space

· Wellbeing Hub

8. Patient Satisfaction

8.1. The number of complaints that the 111 service has received has directly correlated to the periods of sustained high levels of activity. The month of June 2021 saw 22 complaints received against 126,452 calls offered or 0.01%, compared to 9 in February 2021 against 87,249 calls offered or 0.01% (see Appendix H).

8.2. The complaint themes again correlated with activity levels, with April, May and June 2021 receiving the most complaints for ‘delays in a call back’ (see Appendix H).

9. Combined Ambulance Make Ready Centre, 999 Emergency Operations Centre and 111 Operations Centre

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9.1. Work is progressing on the building of the new and exciting joint 999 Emergency Operations Centre and 111 Operations Centre in Gillingham. This new unit will incorporate the Make Ready Centre for ambulance operations in the Medway area and house the relocation of the 111 Operations Centre from Ashford and 999 Operations Centre from Coxheath.

9.2. This co-location further enhances the integration of and aids the development of synergies between both the 999 and 111 services, which is a key part of the Trust’s Strategic Plan to deliver new integrated services over a wider area. In addition, having both of these services housed in the same building will facilitate the sharing of best practice especially as both are using the same computer system, Cleric, and NHS Pathways as the triage tool. This is a key feature for both services as it allows the continued training and development of staff to undertake both 999 and 111 calls.

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