HEALTH OVERVIEW AND SCRUTINY COMMITTEE

 

03 March 2022

 

South East Coast Ambulance Service Update

 

Report from:         Emma Williams, Executive Director of Operations, SECAmb

Author:                  Ray Savage, Strategic Partnerships Manager (SECAmb)

 

Summary

 

This report follows the detailed update in September 2021 on its NHS 111 Integrated Urgent Care Clinical Assessment Service and further updates the committee on the South East Coast Ambulance Service NHS Foundation Trust’s performance for both NHS 111 and 999 service. Since the update to the HOSC in September, the remainder of 2021 continued to be an extremely difficult operating environment, which the performance figures reflect.

 

The Trust continued with its COVID-19 vaccine programme and following on from staff being offered the Oxford Astrazeneca vaccine during 2021, it was also able to offer staff the booster (third vaccine). This programme started at the beginning of October 2021 and the Trust was able to offer staff both the booster and the Flu jab at the same time.

 

Staff absenteeism directly related to COVID-19 has not only been a challenge to the Trust but also the wider NHS. The Trust’s COVID-19 management team has been supporting staff with the latest government guidance through a series of action cards and the Trust’s track and trace cell. At times, guidance to the NHS has been different to the guidance given to the general public. In early 2021 the Trust had in excess of 420 staff absent.

 

The Make Rady Centre at Falmer has been well received by front line crews since its opening in December 2020 and has been visited by other ambulance services to understand the efficiency and effectiveness that this type of operation offers not only to vehicle preparation and maintenance but also the facilities offered to staff.  The latest MRCs in development are, Medway, Kent and Banstead, Surrey, with the Medway MRC not only providing an operational base for ambulance staff but also both the 999 and NHS 111 operational centres and playing a key part in the delivery of the strategic direction of the Trust.

 

Operationally, East Sussex sits within the ‘East’ operational area for 999 and will come under the Medway operations centre, along with Kent & Medway. The NHS 111 IUC CAS covering both Sussex and Kent & Medway will also predominately be provided from this site.

 

1.           Performance

 

1.1.       Throughout 2021, the Trust has continued to be in a challenged position regarding performance across both its NHS 111 IUC and 999 services.

 

1.2.       The continued and sustained pressures, saw the Trust move to Resource Escalatory Action Plan (REAP) level 4 at the beginning of July 2021.

 

1.3.       Additionally, for the first time ever, across the ambulance sector in the UK, all services were operating at REAP level 4, which was a clear indicator of the pressures being faced nationally.

 

1.4.       In July, the Trust also declared a Business Continuity Incident (BCI), in recognition of not only the immediate pressures being placed on the service but the anticipated continuation of these pressures.   

 

1.5.       Two of the key decision factors in declaring the BCI, were the continuing increase in demand place on both the NHS 111 and 999 services, resulting in longer times taken to answer calls to 111 and 999, as well as the length of time some patients were having to wait for an ambulance.

 

1.6.       It was and is fully recognised by the Trust that some patients are having to wait far longer than they should for an ambulance response, particularly those in category 3.  

 

1.7.       Staffing level resilience was another concern that the Trust had, with higher numbers of staff being absent dur to self-isolating as a result of COVID-19.

 

1.8.       For the month of July, calls into 999 were approximately 25% higher than the same period the previous year.

 

1.9.       A media campaign initiated by the Trust during May of 2021, has asked the public for their help to only call for an ambulance in situations where it was a life-threatening emergency.

 

1.10.    As a response to these pressures the Trust developed an ‘Performance Improvement Plan’ to focus on the key areas that directly related to overall performance e.g.  hours of resource (both ambulance and in the EOC), available on a daily basis, activity forecasting and demand planning, job cycle time etc.

 

1.11.    A consequence of the challenges faced by the Trust and a delayed ambulance response was the increase in duplicate calls to 999, where the caller was asking for an update on the expected time of arrival for the ambulance.

 

1.12.    These duplicate calls added to the pressure on timely call answering.

 

1.13.    The Christmas and New Year period presented a number of additional challenges, including the 4-day weekend when alternative services would not have been as readily available.

 

1.14.    Incentivised shifts were being offered for all front-line staff as well as ‘bonus’ for working certain priority shifts. This Trust also applied its annual leave policy, which for the Christmas and New Year period reduces the number of staff allowed off on annual leave at any one time.

 

1.15.    Activity during this period slightly reduced prior to Christmas but the levels of activity during New Year and in particular New Year’s Eve, were 20% higher than the previous year.

 

1.16.    On the 26 January, the Trust’s executive team, made the decision to stand down the BCI and reduce the REAP level to level 3.

 

1.17.    These decisions were taken, based on a comprehensive review of the current service delivery and system pressures and whilst it was recognised that the Trust’s position remained challenged in some areas, it was also recognised that during the first few weeks of 2021, there has been a stabilisation in demand which required a review of the level of REAP that the Trust was operating at.

 

1.18.    The Trust continues to apply its Surge Management Plan (SMP), levels 1 – 4, in response the ‘on the day’ activity challenges.

 

1.19.    Whilst the Trust’s overall performance is not achieving the national standards for both NHS 111 and 999, the levels of performance are in line with and in some cases ahead of the national averages, again reflecting the overall pressures being experienced for all ambulance and NHS 111 providers.

 

1.20.    The Trust is continuing to develop its programme ‘Better by Design’, as a key vehicle for delivering the Trust’s strategic objectives, including operational performance. This programme will be a key focus for the Board over the next months.

 

2.           NHS 111 Integrated Urgent Care Clinical Assessment Service

 

2.1.       As reported to the HOSC in September 2021, the Trusts NHS 111 IUC CAS, experienced unprecedented levels of activity during February 2020. This increase in activity did slightly decrease during March, however higher levels of activity than forecast continued throughout the summer and autumn of 2020, and remined high into the winter months.

 

2.2.       The sustained higher levels of activity continued throughout 2021 and exceeded the commissioned levels that had been expected.

 

2.3.       This continued high level of activity required the Trust to start urgent dialogue with its Kent & Medway and Sussex commissioners regarding funding to increase the workforce for both, call answering (Health Advisors) and clinicians in Clinical Assessment Service to.

 

2.4.       This cross organisational collaboration, including NHS England/Improvement, continues, underpinned by robust activity modelling and forecasting to understand and prioritise further investment within the service.

 

2.5.       The 2021 Christmas and New Year period proved to be particularly challenging with the week commencing 27 December having highest level of activity seen since the start of the contract when calls offered reached 39,500. Appendix A

 

2.6.       The call abandonment rate, often in correlation to higher than forecast levels of calls, reached a high of 31.75% for the week commencing 27 December.  Appendix B

 

2.7.       The service level (calls answered within 60 seconds) reached a new low of 9.9% during October 2021, however due to the continued increase in staffing numbers, the week of the 27 December the service level achieved 21.50%. Appendix C

 

2.8.       The referral rate for ambulance has remained consistently around 9% and is the result of the validation undertaken for category 3 & 4 ambulance dispositions. The validation for all ambulance dispositions has remined consistently around 95%. Appendix D

 

2.9.       Referrals to an Emergency Department (ED) have also remained consistent and through CAS validation around 50% of referrals have been downgraded to alternative end points. Appendix E

 

2.10.    Direct access bookings for December 2021 and January 2022, averaged 23,000 or c31% of all cases triaged within the CAS.

 

2.11.    The ongoing recruitment into NHS 111 saw 52 new staff added to the 111 team during January: 12 additional clinicians into the CAS and 40 Health Advisors.

 

2.12.    Despite these challenges, the clinical outcome performance for the NHS 111 IUC CAS, has continued to meet its contractual requirements and remains in the top quartile of national performance across NHS 111 providers for both emergency department and ambulance referral rates. Appendix F

 

2.13.    This level of performance, as indicted, is supporting our commissioner’s primary objective of creating a safe and effective service (achieving c50% clinical contact for patients), which is protecting the wider Integrated Urgent and Emergency Care (IUEC) system, through its minimisation of both 999 and ED referrals (2.7 & 2.8), underpinned by excellent interoperability and optimisation of Direct Access Bookings (DAB).  

 

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.       The CAS has continued to validate calls received by NHS 111 and as outlined in section 2, through clinical validation has reduced the number of ambulance dispositions and referrals to ED.

 

3.4.       The level of clinical expertise and support 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

 

3.5.       NHS 111 has established itself 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, as well as being made available to staff in care homes who can access clinical support via the Starline star 5 number.  

 

3.6.       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.           999 Service

 

4.1.        Throughout 2021 the Trust’s 999 service has struggled to achieve its Ambulance Quality Indicators (AQI), for both is emergency Operations Centre (EOC) call answering and ambulance response times. This challenge in achieving the AQIs has not been isolated to SECAmb but has affected all ambulance services across England, including the wider UK.

 

4.2.        December 2021 saw a mixture of activity patterns with the immediate run up to Christmas being lower than expected however in the run up to the New Year activity was higher than the same period the previous year. It has to be noted that brief spikes in activity cause operational pressure for the Trust.

 

4.3.        For January 2022 the Trust achieved: Category 1 (C1) ‘mean’ time of 00:08:44 (England mean 00:08:31) and was positioned 8th out of the 11 Trusts measured against a target of 00:07:00. C1 90th percentile was 00:15:57 and positioned 8th against a target of 00:15:00. Category 2 (C2) ‘mean’ was 00:28:21 (England mean 00:38:04) against a target of 00:18:00 and positioned 3rd.  C2 90th percentile was 00:56:54 against a target of 00:40:00. Category 3 (C3) ‘mean’ of 02:01:31 (England 01:56:52) against a target of 00:02:00 and positioned 6th. C3 90th percentile 04:2134:40 (England 04:47:18) and positioned 6th. Whilst these results are still below the required quality indicators, it is noted that performance has improved compared to the previous month (December 2021). Appendix. G

 

4.4.        Whilst performance is slowly improving the Trust recognises that it needs to continue to make improvements, especially in C3 performance.

 

4.5.        999 call answering has been on an improvement trajectory since August 2021, in part, due to the additional winter monies funding made available to ambulance services to recruit additional Emergency Medical Advisors (EMA) responsible for answering the 999 calls.

 

4.6.        The additional funding of £55 million made available by the government to specifically support the recruitment of staff into the 999 Emergency Operations Centres, of which SECAmb received approximately £4.7 million.

 

4.7.        In January and as a part of the Trust’s ongoing recruitment programme, our CEO welcomed 56 new Emergency Medical Advisors (EMA) to the Trust. They will be placed in both our Crawley and Coxheath operations centres.

 

4.8.        The Trust has also been recruiting clinicians, to provide clinical support to the EMAs as well as validating category 3 & 4 ambulance dispositions and supporting ambulance crews at the scene of an incident requiring a clinical conversation about a patient. 

 

4.9.        January’s (2022) call answering was 12 seconds compared with the England ‘mean’ of 19 seconds. The 90th percentile for the Trust was 86 seconds compared to England’s 138 seconds. The Trust’s position was 4th and 5th respectively compared to the 11 ambulance services in England (including the Isle of Wight). Appendix H

 

4.10.     This performance is a significant improvement when for August 2021, the Trust found itself the worst performing trust compared the 10 other ambulance services, with a call answering of 42 seconds (mean) against the mean for England of 26 seconds.

 

4.11.     One of the challenges facing the ambulance sector is the change in activity profile and acuity of calls received. The Ambulance Response Programme is predicated on the more serious of categories of response i.e., C1 and C2, representing approximately between 55-60% of total activity and urgent activity i.e.C3 and C4, representing between 40-45%. However, October saw c74% of C1 and C2 activity, which requires a greater level of response per incident than the Trust’s business is based upon. 

 

4.12.     During 2021, the media was widely reporting on the challenges faced by ambulance services in England and the wider UK with a focus on patients having long waits for an ambulance response and handover delays at hospitals.

 

 

5.           Make Ready Centre and Combined 111 and 999 Operations Centre - Medway

 

5.1.        The Trust is continuing with its development of its new purpose built, four-story, combined Make Ready Centre in Bredgar Road, Gillingham.

 

5.2.        Not only will this exciting venture provide a new base from which our front-line operational staff will report into but also a vehicle preparation and maintenance area, as well housing the relocating NHS 111 Integrated Urgent Care Control Centre & Clinical Assessment Service (NHS 111 IUC CAS) from its current location in Ashford as well as the Trust’s 999 Emergency Operations Centre (EOC) currently based in Coxheath.

 

5.3.        SECAmb’s Make Ready system, which is already in place across much of its region, is a vehicle preparation system which sees specialist teams of staff employed to clean, restock and maintain the Trust’s fleet. 

 

5.4.        The Make Ready Centre will also have on its two upper floors, an open plan office with training, rest and wellbeing facilities.

 

5.5.        These changes will vastly improve the working environment for our 999 EOC and NHS 111 IUC CAS colleagues but will also align with the Trust’s West EOC in West Sussex, which in 2017 saw the control room services from Banstead in Surrey and Lewes in Sussex, relocated into the brand-new Nexus House on Gatwick Road, Crawley.

 

5.6.        The approach of having combined 111 and 999 services collocated, makes the Trust only the second ambulance service in England to do this and by bringing both services together under the one roof will enable an improved resilience and support for each service as well as delivering further benefits for both staff and patients by operating in a more coherent and collaborative way. This move also realises the ambitions outlined in the Trust’s 5-year strategic plan in the delivery of new and integrated urgent and emergency care services across the region.

 

5.7.        It is anticipated that the building works will have finished and handed over to Trust during September 2022 with occupation taking place during Q3 2022.

 

5.8.        As with any relocation of services, staff uncertainty is always a key concern, and the Trust has undertaken a programme of scheduled meetings with all minutes being made available on the Trust’s intranet for all staff to have access. The intranet also has displayed the floor plans, car parking options, travel plans, as well as the feasibility study and business cases, to ensure that all staff affected have access to all relevant and key documentation/information.

 

5.9.        All staff have been offered 1-1 meetings, where individual needs/concerns can be discussed with the management team, and full support is being given by the Trust’s wellbeing team.

 

5.10.     In addition to the 1-1 meetings, webinars have also taken place, which have been recorded for those staff who were unable to make the live sessions and are available on the Trust’s intranet.

 

5.11.     The key Project Board meetings minutes are available on the Trust’s intranet for all staff to have sight of.

 

6.           Brighton Make Ready Centre

 

6.1.       Having opened in December 2020 the Brighton MRC has now been in operation for over 14 months and in line with other MRCs, has helped achieve the optimisation of vehicle (ambulance) preparation and maintenance as well as enabling ambulance crews and support staff to work from a facility that is modern in design and provides training facilities to support staff in maintaining their clinical professional development (CPD).

 

6.2.       The MRC has been visited by several other ambulance services to understand how they operate and the operational efficiencies they deliver. 

 

7.           Banstead Make Ready Centre

 

7.1.     Due to open this spring, Banstead will the Trust’s 10th MRC, and following the designs of previous MRCs, will provide a vehicle preparation and maintenance, as well as bosting modern staff rest, wellbeing, and training facilities. Again, Banstead will have open plan office spaces for corporate services to operate from.

 

7.2      Make ready centers, in most cases will see the closure of existing older ambulance estate with the MRCs becoming the main hub for staff and vehicle reporting, however the Trust will continue to invest in its Ambulance Community Response Posts (ACRP), placed in strategic locations. Each ACRP will have facilities for crews to either be ‘on standby’ or to take their meal break at. Some of the ACRPs are collocated with other emergency service providers.

 

 

 

 

8.           IT Critical Incident

 

8.1.     As a part of ‘business as usual’ there are regular updates to the Trust’s IT infrastructure and during the early hours of the 17 November 2021, the first of a two phased IT update was initiated, resulting in the Trust experiencing an IT system failure.

 

8.2      In a response to this failure, the Trust declared a critical incident.

 

8.3      As a part of the Trusts preparedness and resilience, emergency contingences were enabled to ensure that 999 calls were received, and ambulances dispatched. Six ambulance services supported the Trust with 999 call answering.

 

8.4      At 23:15 on the 17th, the IT systems were back online, and the Critical Incident stood down.

 

8.5      Due to a critical incident being declared, a formal investigation was conducted, and the findings are currently being evaluated.

 

9.           Electric Vehicles

 

9.1.        The Trust has recently been successful in receiving some funding from NHS England to start a trial of some electric vehicles. The Trust is initially looking at Mercedes eVitos. This is in addition to the work that the Trust is undertaking in developing a range of zero emission double-crewed ambulance prototypes. This work being undertaken is in line with how the NHS is moving towards a ‘Net Zero’ NHS outlined in its published strategy of October 2020

 

10.       Executive Appointment

 

10.1       Robert Nichols has been appointed as the Trust’s new Executive Director of Quality & Nursing following the resignation, in July, of Bethan Eaton-Haskins. Bethan had agreed to stay with the Trust until December and support the Trust’s efforts in response to the pandemic. Robert joins the Trust from the Imperial Collage Healthcare NHS Trust where he held the position of Director of Nursing Division of Medicine and Integrated Care. Robert has recently taken up his position within the Trust.

 

11.       Recommendations

 

11.1       The committee is asked to note and comment on the update provided.

 

 

Lead Officer Contact

Ray Savage, Strategic Partnerships Manager (SECAmb)

 

 

 

 

 

 

Appendices

 

Appendix A – KMS 111 IUC - Calls Offered

 

Appendix B – KMS 111 IUC - Abandonment Rate

 

Appendix C – KMS 111 IUC - Calls offered and service Level

 

 

 

Appendix D – KMS 111 IUC – Ambulance Referral Rate

 

 

 

Appendix E – KMS 111 IUC – Emergency Department Validations

 

 

 

Appendix F – KMS 111 IUC - Overview

 

 

Disposition/Month

Dec-20

Jan-21

Feb-21

Mar-21

Apr-21

May-21

Jun-21

Jul-21

Aug-21

Sep-21

Oct-21

Nov-21

Dec-21

Target

111 to 999 referrals*

13:90%

14:90%

15:00%

13:40%

8:70%

9:10%

9:70%

9:30%

9:30%

9:10%

8:90%

8:95%

8:51%

13:00%

A&E Dispositions

14:60%

14:70%

15:40%

15:60%

15:20%

14:90%

16:00%

9:10%

8:10%

8:90%

8:30%

8:70%

8:25%

9:00%

up

n/a

n/a

n/a

48:10%

48:20%

45:20%

44:90%

46:00%

46:00%

46:20%

48:00%

49:35%

52:17%

50:00%

Ambulance C3/C4 Validation

n/a

n/a

n/a

95:40%

95:30%

95:10%

90:60%

95:20%

93:60%

95:90%

95:60%

94:90%

96:86%

85:00%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Appendix G – Ambulance AQI – January 2022

 

 

 

 

 

 

Appendix H – Emergency Operations Centre – 999 Call Answering

 

 

 

 

 

 

 

 

 

 

 

 

Call Answer Times

Mean

 

Call Answer Times

90th centile

 

 

England

19

 

England

59

 

 

1

East Midlands

5

 

1

East Midlands

3

 

 

2

West Midlands

8

 

2

Isle of Wight

14

 

 

3

Isle of Wight

9

 

3

West Midlands

21

 

 

4

South East Coast

12

 

4

North West

33

 

 

5

North West

13

 

5

South East Coast

38

 

 

6

London

14

 

6

North East

44

 

 

7

Yorkshire

17

 

7

Yorkshire

44

 

 

8

North East

18

 

8

London

54

 

 

9

South Central

29

 

9

South Central

111

 

 

10

East of England

36

 

10

East of England

117

 

 

11

South Western

44

 

11

South Western

152

 

 

 

 

 

Call Answer Times

95th centile

 

Call Answer Times

99th centile

 

 

England

108

 

England

226

 

 

1

East Midlands

9

 

1

West Midlands

66

 

 

2

West Midlands

33

 

2

Isle of Wight

107

 

 

3

Isle of Wight

47

 

3

East Midlands

116

 

 

4

North East

73

 

4

North East

160

 

 

5

South East Coast

84

 

5

South East Coast

185

 

 

6

North West

85

 

6

North West

189

 

 

7

London

98

 

7

London

198

 

 

8

Yorkshire

108

 

8

South Central

303

 

 

9

South Central

173

 

9

Yorkshire

310

 

 

10

East of England

207

 

10

South Western

397

 

 

11

South Western

238

 

11

East of England

398