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1. Introduction
1.1. The role of the Welsh Ambulance Service is to provide high quality pre-hospital and emergency care to the people of Wales. The Service is focused on delivering a clinically-led model of care, with a remit which extends beyond the traditional “transport” model of services to one which is firmly rooted in the overall unscheduled care system in Wales.
2. Background
2.1. There is much scrutiny currently of the Ambulance Service’s performance, particularly in terms of its compliance with the primary A8 target, which requires that 65% of arrivals on scene to the most serious 999 calls are within eight minutes. The most recent validated data available at the time of writing (January 2015) puts current performance at some 48.5% against the 65% target.
2.2. However, it is important to note that response to the most critical and immediately life-threatening calls, which are categorised as RED 1 calls, was 62.8% in the same period; the Welsh Ambulance Service’s total A8 performance comprises an aggregation of performance on RED 1 and RED 2 (the next most urgent category) calls.
2.3. Table 1 below shows the trajectory of performance against the primary A8 target in the current financial year and in terms of RED 1 performance over the same period.
Table 1
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Table 1
3. Drivers Influencing Performance
3.1. In considering the Service’s current performance, it is important to put it into the context of the overall unscheduled care system and the changing societal, demographic and financial landscape in which the Service is operating. In brief, these drivers can be summarised under the three headings of demand, supply and finance.
4. Demand
4.1. Overall demand on the Emergency Medical Service (EMS) has risen by 3% year-on-year
4.2. Patient Demography has altered: the frail/elderly population now accounts for 50% of all ambulance requests
4.3. Health needs are changing: ambulance requests from elderly frequent callers has increased by 253% in 7 years
4.4. There has been a change in public expectation, evidenced by increased demand on the full suite of emergency services
4.5. Table 2 demonstrates that, between April 2010 and December 2011, WAST consistently hit its A8 performance target and, in most cases, performed better than 65%. In December 2011, the Trust changed its clinical response model (CRM) for sound clinical reasons. The CRM is the method by which incoming 999 calls are prioritised. Prior to the change, only the public 999 calls counted towards the 65% target; after the change, both the public 999 calls and relevant (RED1 & RED2 incidents) Health Care Professional (HCP) calls were included within the target. This led to an increase of 32% in Category A incidents requiring an eight minute response and had the effect of destabilising the ambulance deployment model. As can be seen from the graph, there is a very clear correlation between the implementation of the changed CRM and performance against the A8 target.
Table 2
5. Supply
5.1. Pressures on the whole unscheduled care system have sometimes led to significant handover delays at emergency units. This presents risks to patients waiting in vehicles and also removes ambulance resources from the community, which presents an arguably greater risk to those “patients” in the community for whom we have no resource available.
5.2. Table 3 below demonstrates how, as the pressures in the unscheduled care system in Wales have increased, the delays in handover have also increased.
Table 3
5.3. While there is generally a clear correlation between handover delay and performance against the A8 target in discrete LHB areas, this is not always the case. For example, in the Cwm Taf UHB area, handover is consistently the best in Wales but performance is regularly very poor, a function of available resources being “pulled out” of the area to support those neighbouring areas where handover delays are acute, resulting in depleted ambulance resources in those neighbouring communities. The Welsh Ambulance Service, working closely with health board colleagues, is addressing these issues, with a whole system improvement approach being introduced in the Cwm Taf area by April 1, 2015 at the latest.
5.4. Workforce numbers have remained fairly static over the last four years. While there has been some internal skill-mixing, e.g. the development of the advanced paramedic practitioner, there is more work to do to enable and develop the workforce to provide the type of care now needed to meet current and projected future demand. Recent investment in recruitment will pay dividends in this respect, as will a welcome increase in paramedic training numbers.
5.5. Attendance levels have deteriorated. There are multiple factors for this, including an ageing workforce, significant occupational stress and a turbulent/unstable organisational culture. The Interim Chief Executive is bringing a sharpened focus to workforce issues, including relationships with the Trades Unions, engagement and roster planning to support improvement in this critical area.
6. Finance
6.1. While the Welsh Ambulance Service has traditionally broken-even financially each year, this has been achieved with increasing levels of significant non-recurrent support from Welsh Government, Commissioners, non recurrent savings and internal financial recovery measures.
6.2. Such financial instability makes planning effectively more difficult and, while significant additional in-year funding in 2014/15 is welcome and reflects the impact of additional demands on the service, the Trust recognises that its Integrated Medium Term Plan (IMTP) needs a full financial analysis and subsequent financial plan which will allow the organisation to operate on a more sustainable financial footing. The analysis will identify the consistent underlying financial challenge which the organisation faces.
6.3. While commissioning arrangements are new and maturing, the development of a collaborative Commissioning, Quality and Delivery Framework will have a positive impact in supporting a more stable financial planning process in the future.
7. Current Organisational Priorities
7.1. The Ambulance Service is entering a period of significant and accelerated change – it needs to stabilise and re-orientate, with a focus on sustained performance improvement.
7.2. The Trust’s Strategic Transformation Programme is making progress and updates are regularly provided to Welsh Government. Similarly, the Trust’s Integrated Medium Term Plan will provide a focus for longer term, sustainable change.
7.3. The past six months have seen a very clear focus on securing an accurate diagnosis of the organisation, its performance and what needs to be done, both internally and with partners across the healthcare system, to improve matters. At the heart of this have been a number of priorities including:
- Supporting our workforce to improve performance, for example by improving relationships with Trades Unions, investing in the workforce in key pinch-point areas (currently a major recruitment drive in South East Wales), improved roster planning to align better capacity with demand, a concerted effort to reduce absence, improving morale by working with staff to find solutions to the challenges faced and agreeing in partnership a set of critical workforce policies, to improve performance, safety and working conditions for staff
- Building organisational capacity with a clear clinical focus to drive forward improvement in performance, for example using clinicians in our Clinical Control Centres to provide enhanced clinical triage of calls, introducing “Paramedic Pathfinder” which provides support for clinical decision-making at the frontline and adopting a whole system approach to improve performance in discrete areas, for example in the Cwm Taf UHB area.
8. Organisational Ambition
8.1 There is a very clear understanding within the Welsh Ambulance Services NHS Trust that sustained improved performance must be achieved and that status quo is not an option. 2015/16 will be a critical year in driving improvement, predicated on:
· The introduction of a revised clinical model
· The adoption of the CareMore five step model/ambulance pathway via the Trust’s Integrated Medium Term Plan
· A programme of public education in partnership with health boards and other agencies to inform, educate and reduce demand
· Being a significant partner in (if not hosting of) the new 111 service
· Consolidating relationships with commissioners and the Ambulance Commissioner to ensure smooth relationships and a shared understanding of capacity, demand and future model of care
· Being a strengthened and refreshed organisation which is responsive to change, innovative and pro-active in driving sustainable improvement
9. Concluding Remarks
9.1 While recognising that the Welsh Ambulance Service has been through a turbulent and challenging few years, it is important that both the workforce and, importantly, the people of Wales, can have confidence in the service and its performance.
9.2This will require relentless focus, pace and discipline, which the Board of the Welsh Ambulance Services NHS Trust is committed to providing, predicated on a shared vision of the future which has been developed collaboratively with the organisation’s stakeholders and which positions the service firmly at the heart of the unscheduled care system in Wales.