HEALTH OVERVIEW AND SCRUTINY COMMITTEE

29 June 2023

South East Coast Ambulance SERVICE NHS FT Update

Report from: Matt Webb, Associate Director, Strategic Partnerships and System Engagement (SECAmb)

Author: Ray Savage, Interim Head of Strategic Partnerships (SECAmb)

Executive Summary

Following the last update to the HOSC in September 2022, the Trust has been operating under sustained pressure, particularly in the run-up to Christmas 2022. This pressure was not only applicable to the Trust but also to the wider NHS. Factors contributing to this pressure include demand on both the 999 and 111 services, delayed handover at hospitals, staff absenteeism, and industrial action. The media has regularly highlighted these pressures, including bed occupancy in hospitals, busy emergency departments, and difficulty in getting appointments in Primary Care.

However, there have been successes in collaborative working between the Trust, community providers, and commissioners. These include the introduction of community-based falls response teams, a single point of contact for Urgent Community Response, and daily communication between the Trust's Integrated Urgent Care team and community providers. This allows community clinicians to review and identify appropriate patients for their teams to respond to, instead of sending an ambulance.

Efforts have also been made to improve patient handover processes and reduce ambulance handover delays. The number of hours lost to handover delays nationally and locally has significantly improved since the last update to the HOSC.

1. Performance

1.1. Since the update in September 2022, the Trust, along with NHS system partners, has faced sustained pressure due to consistently high activity levels. This pressure persisted even during the summer, when the demand placed on the NHS did not decrease as expected. Consequently, there was significant anxiety surrounding the approach of the winter season in 2022/23.

1.2. This pressure persisted throughout the winter months, accompanied by the usual seasonal ailments. However, there was an increase in levels of flu, a resurgence of COVID, and cases of Respiratory Syncytial Virus (RSV) among younger individuals. These factors collectively contributed to the NHS operating under significant and sustained pressures during the winter months.

1.3. There was much coverage in the media during the winter months, often ambulance response times would be combined in the reporting alongside handover delays at hospitals.

1.4. According to the latest NHSE Ambulance Quality Indicators (May 2023), there has been an overall improvement in ambulance response times for all ambulance services. The mean response time for category 1 responses is 00:08:17, and for category 2 responses, it is 00:32:24. It is important to note that the national response time indicators for category 1 and category 2 are 00:07:00 and 00:18:00, respectively. However, as part of the NHS England 'Urgent and Emergency Care Recovery Plan,' ambulance services across England have been set a 30-minute mean response time for 2023/24. (Please refer to Annex A for more details)

1.5. The Trust has shown improvement in its response times since the last update to the HOSC. In May 2023, the Trust reported the following (for more detailed information, please refer to Annex A):

· Trust Category 1 (C1) mean response time was 00:08:11, which is slightly higher than the AQI target of 00:07:00. The Trust was positioned 4th in this category, while the national mean response time was 00:08:17.

· The Trust's C1 90th percentile response time was 00:15:37, compared to the AQI target of 00:15:00. The Trust was positioned 6th in this category, while the national 90th percentile response time was 00:14:45.

· For Category 2 (C2) responses, the Trust's mean response time was 00:24:47, lower than the interim AQI target of 00:30:00. The Trust was positioned 2nd in this category, while the national mean response time was 00:32:24.

· The Trust's C2 90th percentile response time was 00:50:21, higher than the AQI target of 00:40:00. The Trust was also positioned 2nd in this category. The national 90th percentile response time for C2 was 01:09:45, and the Trust was positioned 7th.

· The Trust's Category 3 (C3) 90th percentile response time was 03:49:57, significantly higher than the AQI target of 02:00:00. The national 90th percentile response time for C3 was 01:09:45.

· In the Category 4 (C4) category, the Trust's 90th percentile response time was 05:09:02, higher than the AQI target of 03:00:00. The Trust was positioned 5th in this category, while the national 90th percentile response time was 05:35:00.

1.6. C2 numbers continue to account for over half of the total activity received by ambulance services nationally, and the activity profile of the Trust is in line with this trend.

1.7. 999 call answering times remain a challenge, with May indicating an average call answering time of 21 seconds compared to a national mean of 9 seconds. The Trust is currently in 10th position regarding call answering times.

1.8. Overall, the Trust has been on an improvement trajectory following a highly challenging period leading up to Christmas 2022. This improvement is evident in the charts illustrating response times from April 2022 to the beginning of June 2023. The slight upward trend observed in early June is attributed to the arrival of warmer weather. (Please refer to Annex B for more details). Some of these improvements in response times can be attributed to a reduction in 999 call volume, which is reflective of the national situation. However, it is important to note that the existing pressure across the wider system still affects all NHS provider partners.

1.9. The Trust maintains constant monitoring of its workforce, with recruitment and retention being a top priority. The ongoing recruitment and training of staff, coupled with attrition in the Trust's Emergency Operations Centres (999) and the NHS111 Contact Centre, have at times exacerbated rota fill challenges during periods of high annual leave and sickness absence. Consequently, this has led to increased sickness and staff turnover. For frontline staff, the Trust is currently within 2.5% of full staffing levels, and following the recent Trust-wide rota review, all reviewed rotas are expected to align with activity demand by July.

1.10. Winter 2022 proved to be very challenging for the Trust’s KMS 111 service. December alone saw an increase of up to 30% in call activity. The service has remained challenged and call activity for April was 104,975 of which 15,422 (14.69%) were abandoned. Calls answered within 60 seconds was 31,057 or 39.09%.

1.11. Ambulance validation is when Clinicians in the Clinical Assessment Service (CAS) supported by CAS Clinical Navigators validate ambulance dispositions. For April, KMS 111 was required to validate 6,857 Category 3 & Category 4 ambulances, of which 6,524 (95.14%) were validated, resulting in 4,083 (62.58%) ambulances successfully stood down and the patient redirected to a more appropriate level of care.

1.12. The Trust’s service continues to remain one of the lowest nationally with only 6.54% of ambulance referrals. The service also remains one of the better performing nationally when booking a patient an appointment into other services e.g., Emergency Department, Primary Care (inc. Urgent Treatment Centres).

2. Ambulance Handover

2.1. Nationally, the hours lost to ambulance handover delays have reduced to a lower level compared to the previous year. In April 2023, there were an average of 770 incidents per day with delays greater than 60 minutes, compared to 1,380 incidents in April 2022, resulting in 899 hours lost compared to 2,362 hours lost for the same period (average per day).

2.2. Handover delays within the Trust's operational area align with the national trend, showing notable reductions. This can be attributed to several factors (refer to Annex C):

· The Trust has experienced a reduction in activity demand.

· Frontline managers have collaborated with their respective acute trust management teams to review processes in the emergency department, enabling quicker and more efficient patient handover procedures.

· Acute Trusts have collaborated with system partners to reduce bed occupancy and improve patient flow throughout the hospital.

· The Trust, in collaboration with acute Trust partners, closely monitors activity in the emergency departments and ambulance patient handover delays on an hourly basis. In addition to the joint efforts of Trust and acute hospital management teams to alleviate delays, hospitals can request an "ambulance divert" for a short period of time to reduce pressure in the emergency department.

2.3. The four main hospitals for East Sussex patients are:

· Eastbourne District General Hospital (EDGH)

· Conquest Hospital

· Tunbridge Wells Hospital (Pembury)

· Royal Sussex County Hospital (RSCH)

These four hospitals have also shown reductions in delays greater than 60 minutes (refer to Annex D).

2.4. The Trust's respective operational teams work closely with the teams within each emergency department and senior leaders for emergency medicine.

2.5. Collaborative working with EDGH and the Conquest Hospital has led to a significant reduction in hours lost per journey. Key developments between the Trust and East Sussex Healthcare Trust include:

· The introduction of Rapid Assessment and Triage areas to improve the speed at which patients arriving by ambulance can be assessed and triaged.

· Direct access to the Same Day Emergency Care (SDEC) team, allowing ambulance crews to speak directly to hospital clinicians regarding the suitability of a patient for direct access to SDEC and avoiding the emergency department.

· Monthly manager meetings to discuss ambulance handover and identify areas for improvement in the existing process.

· The Trust's local operations managers frequently attend the emergency departments to maintain and build relationships with senior staff.

· Morning resilience calls where all system partners can highlight operational challenges and concerns.

· The time at which ambulances arrives at hospital (GeoFence) has been reviewed to capture and accurate arrival time.

These actions have successfully reduced the hours lost at both hospitals (refer to Annex E).

2.6. Ambulance handover has been particularly challenging at RSCH over the past few years, partly due to physical constraints of the estate. While corridor care is inappropriate, unlike neighbouring hospitals, the entrance to the emergency department at RSCH is restrictive, allowing only a limited number of crews at a time to enter the department and prepare for a clinical handover. One of the key challenges faced by the hospital is patient flow and high levels of bed occupancy. However, when bed occupancy is lower and patient flow higher, handover performance improves. The occupation of the new Louisa Martindale Building is expected to positively contribute towards this from the end of June 2023.

2.7. The Trust's management team has been working with managers at RSCH to improve patient handover processes and has established good relationships. Although RSCH poses more challenges compared to other Sussex hospitals, both hospital managers and the Trust's management team are working hard to reduce delays. Collaborative working has enabled the following:

· Weekly meetings of senior leaders from both ambulance and hospital teams to review challenges, trends, and patterns causing delays.

· Day-to-day liaison between respective operational leaders to ensure delays are minimised.

· A cultural shift at RSCH towards receiving all ambulances as quickly as possible, despite departmental capacity.

· The development of a QR code for ambulance crews to scan in the department, enabling them to provide feedback or suggestions for improvements.

· A positive trend in performance and a reversal in the deteriorating position since the low of December 2022.

2.8. In May 2023, Tunbridge Wells Hospital experienced no handover delays exceeding 60 minutes. This follows a pattern throughout the year with very low numbers of delays exceeding 60 minutes, thanks to the focused and proactive support from the management and clinical team in the emergency department. Some key actions and processes in place include:

· Ambulances en-route to the hospital appear on the "inbound" screen in the department, and arriving ambulances are checked against available capacity.

· Crews arriving with patients are directed to the Rapid Assessment area, where a dedicated practitioner focuses on receiving the clinical handover from the crew.

· Patient flow into the Rapid Assessment area and other relevant areas is a key focus for efficiency improvements, aiming to ensure a smooth and uninterrupted flow in and out of these key sones.

· An ambulance handover window has been installed, allowing crews to inform the administrative team of the patient they have brought in without having to go to the department's reception and queue to provide patient details.

3. Going Further for Winter NHSE Programme

3.1. During October 2022, NHSE introduced the Going Further for Winter (GFFW) programme. This required a collaborative working approach among ambulance services, community trust providers, and commissioners to enhance the opportunity to reduce avoidable ambulance conveyances to hospitals when an alternative community response (Urgent Community Response) would have been more appropriate. Therefore, the following measures were implemented:

· Working in partnership across Sussex Community Foundation Trust (SCFT), East Sussex Healthcare NHS Trust (ESHT) and East Sussex County Council (ESCC) an Admissions Avoidance Single Point of Access (AASPA) was established to provide ambulance crews with a single contact number for accessing the Urgent Community Response (UCR) Teams. This model builds on the existing admissions avoidance infrastructures which for East Sussex is supported by Health and Social Care Connect (HSCC) as the East Sussex integrated access point to services.

· An acceptance/eligibility criterion was agreed upon, which crews can access via NHS Service Finder. This criterion serves as a guide for crews to follow and is not exhaustive.

· When contacting the community team via the AASPA, a crew can have a conversation with one of the team members to assess the patient's suitability for a referral into the community team.

· SCFT trained their community teams, and ESHT enabled access to their teams, allowing both providers to respond to patients who have dialled 999 and have fallen but have no or minor injuries. The staff in the Emergency Operations Centre can now refer patients directly to the community teams, who can attend the incident, assess the patient, and use the specialised equipment they carry to assist them in getting up off the floor.

· The Trust's Integrated Care team (999/Emergency Operations Centre clinicians) has established daily touchpoints with both SCFT and ESHT. This enables their clinicians to view outstanding urgent C3 and C4 incidents that are waiting to be allocated to an ambulance. It allows the community clinicians to identify any patients suitable for the community team to visit, thereby avoiding the dispatch of an ambulance.

· The Trust is already planning the next step in the daily touch point calls, which is to enable direct access for the UCR clinicians to the category 3 and category 4 clinical stack via a web portal. This will be a significant development as it removes the daily touchpoint call and enables full access to the ‘stack’ for the community teams to regularly review.

3.2. This programme, while having transitioned to Business-as-Usual, remains a significant focus for SCFT, ESHT, the Trust, and commissioners to further develop opportunities to increase the number of patients being referred and accepted into UCR. In addition to enhancing ambulance access to UCR, the Trust has been collaborating with Sussex Partnership Foundation Trust (SPFT) and Sussex ICB to improve ambulance responses to patients in mental health crisis.

3.3. In Northwest Sussex, the Blue Light Triage (BLT) model has been piloted to enable direct access for both police and ambulance staff to the mental health crisis team, who can provide clinical advice and support over the telephone to those attending the incident. Where appropriate, they can also attend the incident location to provide face-to-face intervention and support. Both of these models are supporting the Trust in improving its Hear and Treat (H&T) and See and Treat (S&T) services.

3.4. It has long been recognised that not all calls to 999 warrant an ambulance response or conveyance to the hospital. The Trust has initiated a programme of Category 3 and Category 4 incident validation. These incidents, classified as urgent but not life-threatening, have an ambulance response time indicator of 2 hours and 3 hours, respectively. This programme creates an opportunity for clinical validation, where a clinician reviews the incident and, when appropriate, contacts the patient to discuss their condition in more detail. As part of this approach, band 6 Paramedics have received additional training to enable them to undertake patient call backs.

3.5. The increased clinical review of these categories has started to yield improvements in the Trust's Hear and Treat (H&T) services and ensure the appropriate support/response for the patients, with the Trust having set a target of 14% H&T and looking for an improvement of between 4 and 5% over the current attainment.

3.6. NHS111 Open Access Crisis (OAC), allows patients who require access to urgent mental health support to use 111 as the first port of call (right care first time).

4. Medway Multi-purpose Ambulance Centre

4.1. After several delays, on 8th June, ambulance crews finally relocated to the Trust's newest Make Ready Centre (MRC) in Gillingham. This marks a significant milestone as the Gillingham MRC will also accommodate the Trust's NHS 111 service, which is currently based in Orbital House in Ashford, and the 999 Emergency Operations Centre, which is currently operating from Coxheath.

4.2. This development complements the Trust's Head Office, which currently houses both the 999 and 111 services. Integrating both services is a key component of the Trust's strategy to deliver a more connected and integrated care model while enhancing efficiency.

5. Recommendations

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

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Lead Officer Contact

Ray Savage, Interim Head of Strategic Partnerships (SECAmb)

Background papers

None