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28.1.      The Committee considered a report providing an update on the quality and performance of services provided by South East Coast Ambulance NHS Foundation Trust (SECAmb).

28.2.      The Committee received a number of responses to its questions from the witnesses in attendance.

Category 3 wait times

28.3.      James Pavey, Regional Operations Manager, explained that the Ambulance Response Programme (ARP) Categories are nationally set and are designed to ensure that those patients who are the sickest get the quickest response, but also the most appropriate response and are then conveyed to the most appropriate place of care. This means that during periods of high demand on the service there can be a backlog of less urgent calls (category 3 or 4) which is the result of prioritising the more serious calls and, as identified in the Demand and Capacity review, it is at these times there is insufficient resource to send a response to all calls. He agreed that it is not acceptable that patients triaged to category 3 or 4 have to wait too long and he apologised for the excessive waits that some patients experience, however, he said the additional funding from the Demand and Capacity review would help to address response times in the longer term.

28.4.      Mr Pavey explained that there are escalation plans in place for when the backlog of calls reaches a certain level of approximately 70-80 calls across the Kent, Surrey and Sussex region. This occurs when there are more calls than resources, the service is under severe pressure, and there is a high level of patients waiting for an ambulance, including patients who may not need one. It is during these times the trust does quite a bit of ‘no sending’ to deal with those patients who do not need an ambulance by giving them advice over the phone on other alternative sources of care available to them. He explained that staff will try and give the right advice to these patients over the phone where it appears that they do not need an ambulance, however, sometimes it is difficult to tell what is happening over the phone and it is necessary to dispatch a clinician to visit the patient and determine what care they require.

Falls

28.5.      James Pavey explained that falls are initially categorised under Category 3 (response time of 2 hours) provided there are no other serious symptoms such as shortness of breath. The Trust also carries out welfare call backs for patients who are waiting, and their category will be upgraded if they are displaying more serious symptoms.

Hear and treat

28.6.      It was explained that only about 60% of patients seen by ambulance crews need to be conveyed to hospital, so it is possible to diagnose and treat some patients over the phone through a process called Hear and Treat. James Pavey explained that Hear and Treat uses a national NHS Pathways programme (the programme used to help diagnose over the phone) and is backed up by clinicians within the control room who can offer advice over the phone. He said that it is a challenge to diagnose over the phone compared to in person, but it is a necessary step to help manage demand by sifting out less urgent calls and directing them to other services where necessary. He added that NHS Pathways is a very safe, risk averse programme and patients are more likely to get seen by an ambulance crew than not when they call 999. People sometimes only dial 999 for advice and when they do call handlers are able to direct them to other suitable services. 

Stopping the clock on category 1 calls

28.7.      James Pavey confirmed that in the case of a Category 1 call SECAmb does not deploy Community First Responders (CFR) to simply ‘stop the clock’ on the 7-minute average response time. A CFR’s role is to provide vital lifesaving procedures such as defibrillation to a patient until the ambulance crew/paramedics arrive. It is the ambulance crew/paramedic’s role to stabilise and convey the patient to hospital. However, appropriately trained and equipped CFR’s attendance time is valid under the national standards if the patient does not require conveying. A bystander with a public access defibrillator does not count towards meeting the national standards.

Rural vs Urban response times

28.8.      James Pavey clarified that SECAmb is commissioned to deliver a single response time across the whole of Kent, Surrey and Sussex and not different response times in different areas. However, the difference in urban and rural response times was not a new phenomenon, is a national issue, and has no easy answer. Some of the reasons for the discrepancy included:

• the health service was constructed around hospital sites that ambulances convey patients to and they are based in urban centres, meaning that further travel times to hospital sites from rural areas are inevitable. Over the past 20-30 years hospital sites have been concentrated into fewer and fewer larger hospitals;
• SECAmb organises its resources to match concentrations of people, and because the trust receives most of the 115-120 daily calls across the region for category 1 calls in urban areas the trust focuses its resources there; and
• the low number of rural category 1 calls makes their location quite random, meaning it is difficult to allocate resources in rural areas effectively.

28.9.      He said that some mitigating actions have been taken, such as installing public defibrillators in public buildings in rural areas and training local volunteers to be CFRs.

28.10.   Ashley Scarff added that the HWLH CCG is mindful that its area has the worst response times. The issue is regularly discussed at the CCG’s Governing Body and Quality and Safety Committee meetings, and the CCG reviews individual cases to determine what effect the additional travel time may have had on a patient’s clinical outcomes.  

Demand and Capacity Review

28.11.   Jayne Phoenix, Deputy Director for Strategy & Business Development, explained that the Demand and Capacity Review identified the need for additional investment by CCGs in the trust enable it to meet the ARP response time targets. The trust has developed a detailed transformation programme to ensure that it is able to meet its ARP category targets by Q4 of 20/21 using the additional funding. The achievement of the ARP targets, however, relies on the additional funding helping to deliver a new model of care that involves a number of initiatives including a paramedic recruitment programme; increasing the size of the ambulance fleet – including the recent purchase of 100 new ambulances of which the first few have arrived – and the development of  a ‘non-emergency’ transport fleet to enable the trust to respond to some of the patients waiting longer for an ambulance.

28.12.   Jayne Phoenix said that the trust is also piloting different ways to respond to calls involving falls or mental health issues, where it is recognised that alternative pathways to waiting for an ambulance may be more appropriate. In Surrey the trust has been conducting a new pilot involving a non-emergency vehicle with a paramedic and occupational therapist on board responding to falls.

Delivering the recruitment programme

28.13.   James Pavey explained that the recruitment programme involves an increase in the percentage of paramedics from about 40% to 70% of the workforce. He agreed that achieving this would be a risk but was necessary. He said that it is possible for people to join the trust in a more junior position, e.g. an Emergency Care Support Worker, and work their way up to a paramedic. Local recruitment for Emergency Care Support Workers in areas like Polegate and Hastings is possible because the positions are on a lower pay scale, and they can be filled because there is still an attractiveness about working in the paramedic profession.  He added that it is important to work collaboratively with system partners when developing recruitment plans to avoid losing staff to other organisations.                                                                                                     

28.14.   Jayne Phoenix added that retention was also important and has improved considerably since 2016. The much better response from staff to the NHS Staff Survey also demonstrated improved staff satisfaction, which is likely to improve retention rates. Initiatives to retain staff include improved career development pathways, and a pilot for staff to rotate within the service (on the road and in the control room) and into primary care.

Hospital Handover times

28.15.   James Pavey explained that a delay occurs in a handover of a patient from the paramedics to a hospital A&E department where it takes longer than 15 minutes. Delays are a national issue and significant delays occur across the region SECAmb operates in, although many hospital trusts have made improvements in tackling the issue. This is demonstrated through a 30% year on year improvement during Q3 in terms of hours lost due to hospital handover delays. James Pavey highlighted ESHT as having made dramatic improvements in handover times through working closely with SECAmb, NHS England and NHS Improvement; although not all other hospitals have made as much progress.

28.16.   James Pavey explained that a handover involves a handover of clinical information to give the hospital staff a picture of the reasons why the patient was conveyed to the hospital. The hospital may then triage the patient to the appropriate service within the hospital. Dr Adrian Bull added that ESHT does not try to replicate the ambulance team’s assessment but does take their information on board in their triage. He said that paramedics may call ahead to triage over the phone and be able to attend the surgical assessment unit or the acute medical unit rather than go straight to A&E and wait for a handover to clinicians there.

28.17.   Jayne Phoenix added that all paramedics now have access to a patient’s summary care record via iPads, which are issued to all staff. The level of detail is dependent on who put the detail in and can vary a lot, however, it can assist paramedics attending calls where, for example, a patient may have an end of life care plan in place that includes a ‘do not resuscitate’ request.

Violence against staff

28.18.   James Pavey said that violence against staff is a continuing issue in the NHS and that staff are taught methods of conflict resolution as a means of protection. SECAmb also offers support to staff through a staff welfare and wellbeing hub; records and monitors all incidents of physical and verbal abuse against staff; and will prosecute members of the public who attack staff. Staff also have personal radios to call for help, and body worn cameras may be introduced in the future.

Collaboration with other Trusts

28.19.   Jayne Phoenix explained that the main focus of the collaboration with the West Midlands and South Western Ambulance Trusts, will be around improving procurement practices based on the recommendations of the Lord Carter report. She clarified that it is not a plan to merge or to share staffing. It also helps to maintain national resilience by ensuring that the trusts have the same systems so that in an event of a major incident, for example, they can more easily support each other. 

28.20.   The Committee RESOLVED to:

1)    Request further details on the Trust’s transformation and delivery programme to be circulated by email; and

2)    Request a further report to include details of how SECAmb and hospital trusts are collaborating, including in relation to hospital handover times and the sharing of patient records.