44.1. The Committee considered a report providing an update from SECAmb on a number of areas, including performance against national response times and the new NHS 111 service.
44.2. Ray Savage, Strategy and Partnership Manager at SECAmb, clarified that there was an error in one of the tables in appendix A (p. 53). In the table ‘Sussex CCG performance 2020’, The East Sussex CCG entry for Category 1 said 00:18:18 but it should have read 00:08:18.
44.3. The Committee asked whether there were sufficient resources to meet the category response targets consistently in the future in East Sussex.
44.4. Mark Eley, Associate Director of Operations – East at SECAmb, said the Category 1 and 2 targets are challenging to achieve in East Sussex compared to other areas in its patch, such as Brighton & Hove, due to the rurality of the county. The low population density and country roads make it very challenging to reach a patient in the 7 minutes required for a Category 1 response. Staff sickness due COVID-19 and the winter weather has made it harder in the last few months to respond as quickly. He clarified that the 7-minute performance of SECAmb is taken as an average. Therefore, to balance out the slower response in rural areas, ambulance crews in urban areas such as Brighton & Hove are expected to respond in less time. He added that SECAmb aims to arrive as soon as possible, not just at the mandated response time.
44.5. Mark Eley said the Trust continues to look at all opportunities to improve its performance, including reviewing local standby points to make sure they are in the best place relative to population centres and that the appropriate number of ambulances are located closest to those areas that require them most often, for example, those with higher health inequalities.
44.6. The Committee asked how many clinical staff are working for the Clinical Assessment Service (CAS) and whether they were working in a call centre or remotely.
44.7. Simon Clarke, Head of Operations, Integrated Urgent Care, 999 & 111, said the CAS has approximately 130 whole time equivalent (WTE) clinicians, which is made up of many more individuals due to not all of them doing it full time. This workforce includes General Practitioners (GPs), Advanced Nurse Practitioners, midwives, dental nurses, pharmacists, mental health nurses, and urgent care practitioners. The majority are working remotely, in part due to COVID-19 restrictions, but a certain number are required in the Emergency Operations Centres to be able to give direct advice to call handlers in the call centres when immediate advice is needed for a challenging call.
44.8. The Committee asked about the performance of Think NHS 111 First.
44.9. Simon Clarke said that it launched officially in December, although there had been an earlier soft launch. The aim of Think NHS 111 First is to reduce ED attendance by providing anyone who calls 111 with a disposition that may require them to go to an ED with a call back from a clinician within 30 minutes. If a call back is not made in 30 minutes, they are advised to go to ED. Since December 2020, across the whole of the NHS 111 patch of Kent, Medway and Sussex there have been more than 10,000 people have been put on the Think 111 First pathway. Of those, 9,200 (89%) received a clinical assessment within 30 minutes. 3,900 (42%) of these were advised to go to ED predominantly at a specified time; 2,000 were given an urgent care appointment either at a minor injuries unit, walk-in centre, Urgent Treatment Centre (UTC) or GP appointment; 2,000 were advised to self-care; and 500 (5%) cases were upgraded to an ambulance call out.
44.10. Simon Clarke added that over the course of 2020, bookings from 111 to another part of the health service in Kent, Surrey and Sussex have increased from 300 per month in January to 16,000 in December. He said this shows it is becoming a one stop service for healthcare that provides patients with either over the phone care or a booked appointment to the most suitable part of the NHS for the patient.
44.11. The Committee asked for more details of how the ED bookings work.
44.12. Simon Clarke clarified that the ED ‘appointment’ is not a direct appointment to see a clinician, but a given time slot that the patient should attend the ED. This helps to stagger arrivals at the ED and prevents people having to wait for hours at the ED. Joe Chadwick-Bell added that this is a fantastic way forward for managing patients’ use of EDs and the system has much more potential still to be exploited. The Chief Executive of ESHT said that the Trust does not yet have details of whether patients asked to attend for a certain time frame were seen within that time frame, but this can be provided in the future. Anecdotally patients are seen quickly, but this may be due to the current lower usage of EDs due to COVID-19. Patients may also get told to go to ED by 111 but are still triaged on arrival and sent to the UTC if they are able to be seen by a GP rather than an emergency medicine consultant.
44.13. The Committee asked how NHS 111 deals with people calling up with complex health issues.
44.14. Simon Clarke said that the initial 111 call is taken by a call handler who will go through NHS Pathways to triage the patient. They are not clinicians so do not have access to full care records, but there should be a special patient notice on the system if they have a medical condition that may affect the outcome of the triage on NHS Pathways. In addition, there will always be a clinician in the room who the call handler can receive advice from in complex calls. The patient can also be put in a call back queue with a clinician if needs be. These clinicians will have access to the full patient record through GP Connect.
44.15. Simon Clarke said that NHS 111 CAS is new and has been under immediate, unprecedented pressure due to COVID-19 and therefore some patients may not have received a call back within the specified timeframe. Where this has happened, there is a complaints process that people can use. NHS 111 CAS has continued to improve and is now able provide 50% of callers with a clinical call back, which amounts to 42,000 calls a month across Kent, Medway and Sussex.
44.16. The Committee asked for confirmation what the procedure is for a patient who cannot be stabilised by a paramedic.
44.17. Mark Eley said he understood that if a patient deteriorates in the care of a paramedic they will make the clinical decision to either take the patient to a specialist hospital or to the nearest ED. If it is the latter, they will let the hospital know they are coming.
44.18. Joe Chadwick-Bell added that the most important consideration was reaching a place that can provide definitive care, such as a Hyper Acute Stroke Unit (HASU) for a stroke patient, but if a patient is not stable enough to reach definitive care the ambulance crew will make a decision whether a local hospital is more appropriate. SECAmb also work hard to ensure that they can deliver definitive care on site or on the journey themselves so that they do not need to make this choice.
44.19. Ray Savage said SECAmb conducted a small pilot in East Kent working with the local hospital trust to use telemedicine for stroke patients. This involved ambulance crews contacting a stroke consultant via an iPad when on the scene of a suspected stroke patient, which enables the consultant to assist with the triage of the patient.
44.20. The Committee asked what the guidance was regarding hospital handover times for stroke patients.
44.21. Joe Chadwick-Bell explained that a critically ill patient that walks in or arrives via ambulance will be immediately triaged and handed over to the care of the hospital. If the patient is suffering a suspected stroke, they will go straight to the resuscitation ward and a stroke nurse will be called to attend as soon as possible. The target is to assess the patient and provide them with a medical intervention within an hour of arrival.
44.22. The Committee asked how often the air ambulance is used
44.23. Mark Eley said an air ambulance report is sent to SECAmb each morning showing their availability and criteria for use. They are a significant asset with a highly trained crew so are used as much as possible, where clinically appropriate to do so.
44.24. The Committee asked why so many more hours were lost in December to handover times in East Sussex compared to West Sussex and whether this was due to the westerly spread of the Kent variant of COVID-19 at the time.
44.25. Ray Savage said the figures for December were a snapshot. SECAmb has worked closely with acute Trusts in Sussex through the Joint Commissioning of Ambulance Pathway programme to develop alternative pathways and handover process in EDs. The January and February figures for both hospital sites in East Sussex show a significant improvement in handover times, which is the result in part of SECAmb closely working with ESHT’s ED teams to improve the handover process. He said he is confident that improvement should be sustained and that future updates will reflect the improvement that has taken place.
44.26. The Committee asked if the national 15 minute hospital handover time is realistic given the low compliance rate with the figure.
44.27. Mark Eley said it was a hard target to achieve but is still achieved quite regularly. He also believed it is important that the Trust is challenged and that the target should be hard to reach. There have been challenges during COVID-19, particularly staff being off sick at both SECAmb and the EDs at the hospital sites, which has resulted in challenges with handover times.
44.28. Joe Chadwick-Bell added that from the perspective of ESHT, the 15-minute target is reasonable most of the time. The issue in achieving it has largely been due to the process of how a handover is undertaken and the capacity of the hospital to accept patients. The handover process has now been changed so that handovers take place much more swiftly in purpose-built booths at the hospital sites. Capacity remains an issue, however, as whilst patients who are ‘fit to sit’ in the ED waiting areas can be handed over, those who need to be placed in a cubicle cannot be if all cubicles are full. Likewise, if several ambulances arrive at once, the capacity of the handover teams can be stretched, leading to delays. The Chief Executive confirmed that there are escalation plans in place to help free up space in the ED when it becomes full.
44.29. Ray Savage added that technology is also helping with the process of handover, as ambulance crews can remotely update the electronic patient record of patients inbound so that when they arrive the handover nurses already have an understanding of the condition of the patient. He said he has experienced this working well first hand when he completes shifts as a ambulance crew.
44.30. The Committee asked whether the loss of jobs at Gatwick will help with recruitment to the Crawley Emergency Operations Centre (EOC).
44.31. Simon Clarke said that the disruption to the aviation industry due to COVID-19 has made Crawley a good recruitment area. The EOC is now above the staffing requirement for its NHS 111 contract with 50 111 and 30 EOC 999 staff in place.
44.32. The Committee RESOLVED to:
1) Consider and comment on the update from SECAmb;
2) request a further report in September on NHS 111, including details of the impact on emergency departments from Think NHS 111 First;
3) request a visit to the new ambulance station at Falmer, Brighton; and
4) request that the recommended standards for acute stroke services is provided via email.