Nick Ramsay, AM

Chair 

Public Accounts Committee

 

 

Our Ref: AG/JM/SB

 

21 November 2016

 

 

Dear Mr Ramsay AM

 

RESPONSE TO ACTION POINTS FOLLOWING ATTENDANCE AT PUBLIC ACCOUNTS COMMITTEE SESSION 7 NOVEMBER 2016

 

I refer to my recent appearance at the Public Accounts committee when I agreed to provide further information to you and the committee regarding:

 

·         a description of the clinical conditions that fall within the red, amber and green response times for ambulance calls;

·         further detail on response time figures for amber calls and how the Welsh Government monitors response times for these calls;

·         and update on further investigation regarding management of GP out of hours coverage by health boards.

 

Clinical conditions that fall within the red, amber and green response times for ambulance calls

 

Red calls represent the smallest proportion, but the most time-critical calls received by the ambulance service which have the potential to endanger life in seconds and minutes. One of the primary aims of the clinical model pilot is to improve the response to such calls in order to save lives.  Examples of calls which would be coded as Red calls include patients who are unconscious or in cardiac arrest, patients whose breathing status is uncertain or have abnormal patterns of breathing, hanging/strangulation/suffocation/drowning, and penetrating central wounds.  The median call response in September was 4 minutes 38 seconds.

 

Amber calls represent the largest proportion of calls received by the ambulance service and are considered serious but not immediately life threatening.  In these cases, patients will often benefit more from the most appropriate response rather than the quickest response.  Conditions such as chest pain, stroke and convulsions/fitting are coded as Amber calls. The median call response in September was 13 minutes 23 Seconds.

              

Green calls are considered to be neither serious nor life-threatening.  Conditions such as ear ache or minor injuries are coded as Green calls.  Green calls are often suited to management via secondary telephone triage.

 

In support of transparency, and committed as part of the clinical response model, the ambulance service has developed a clinical response matrix that supports call handlers in choosing the correct response for each type of call.

 

Response time figures for amber calls and how the Welsh Government monitors response times for these calls;

 

Statistical information on ambulance responses is published regularly via the StatsWales website: https://statswales.gov.wales/Catalogue/Health-and-Social-Care/NHS-Performance/Ambulance-Services

 

Information available includes:

·         Emergency ambulance calls and responses to red calls, by LHB and month

·         Emergency responses: minute-by-minute performance for red calls by Local Health Board and month

·         Emergency responses: minute-by-minute performance for amber calls, by Local Health Board and month

·         Ambulance services: median response times (minutes and seconds)

The Emergency Ambulance Services Committee also publishes quarterly Ambulance Quality Indicators via its website: http://www.wales.nhs.uk/easc/ambulance-quality-indicators

 

Information available includes quantitative metrics against each step of the ambulance care pathway and clinical indicators relating to cardiac arrest, stroke, heart attack (STEMI), fractured hip (neck of femur), febrile convulsion, sepsis and hypoglycaemia.

 

Performance against the national target is monitored through regular meetings with WAST and health boards. These quality outcomes are a critical part of the overall evaluation.

 

Management of GP out of hours coverage by health boards.

 

Please refer to Annex A for the detailed response across Wales.

 

 

Yours sincerely

 

Dr Andrew Goodall

Annex A

 

Management of GP out of hours coverage by health boards.

 

Background

 

Out of hours (OOH) covers the period  from 6.30pm to 8am Monday to Thursday, and from 6.30pm Friday to 8am on Monday and bank holidays, during which time  GPs are not required to provide cover as part of the their GMS contract (established in 2004). A GP out of hours service covers these periods, and the local health board (LHB) have responsibility for the management of this service. To ensure that they have sufficient GP cover LHBs use a demand and capacity planning model, seeking to ensure that they have sufficient cover to meet the peak demand which is generally regarded as early evening, particularly as the service goes live at 6.30pm. 

 

While the GP Out of Hours service does experience pressures, these are managed to ensure that patients have access to clinical expertise.

 

Over the last 12 months the service has experienced only one Health Board wide closure and a small number of site closures as shown in the table below.

 

Health Board

Site

HB wide closure

Cardiff and Vale

Yes (see next column)

1 occasion (overnight weekend)*

Aneurin Bevan

Yes planned closure - Nevill Hall (Pilot) with cover across HB

No

Abertawe Bro Morgannwg

Yes - 9 occasions but with cover provided across HB, 111 now providing resilience

No

Betsi Cadwaladr

No

No

Cwm Taf

No

No

Hywel Dda

Yes - 2 occasions but with cover across HB

No

Powys

Yes, 1 occasion but with cover provided

No

 

* Further detail on the position reported by Cardiff and Vale University Health Board

There was one incident where the lack of GP cover led to the OoHs service being closed for a total of 18½ hours during the weekend evenings of the 13/14 August. There were no clinical incidents and GP OOHs call handlers were operating throughout the weekend to manage the existing triage pool and home visits.

 

The UHB mitigated and minimised the impact of short term closures of the service on patients through: discussions with other NHS services to fill shifts; prior agreement with Health Board’s Emergency Departments/NHS direct and other Health Boards; and by having a senior manager personally on call for Primary Care to liaise with other Departments within the Health Board.

 

NHS Direct did have had an increase in activity, and patients were able to be directed to appropriate services. A series of actions have been implemented subsequently, including the adoption of a detailed escalation plan, more demand and capacity analysis and there has been no recurrence.

 

111 Service - driving service change

 

111 provides a real opportunity to co-ordinate and better manage the demand of unscheduled care for NHS Wales, meet the needs of patients within their own communities, avoid unnecessary hospital admission and reduce demand on acute hospital services. Moving forward the intention is to roll out the 111 service across Wales. This will see improvements in the way in which GP out of hours is managed and allow patients to benefit from being able to contact one single, easy to remember, free to call number.

 

Abertawe Bro Morgannwg UHB (AMBU) has been a NHS Pathfinder for the 111 service in Wales. This launched in October and the 111 number is now in use across the whole health board. Some headlines include:

·         Circa 10,500 calls answered up to mid November following the phased launch.

·         The integrated IT solution is fully operational. Staff are now used to the new call flow and it is anticipated that call handling times will reduce over the next 6-8 weeks.

·         New call takers have been recruited to provide additional resilience to the service over the winter period.

·         Mean time to call answer in October was 85 seconds.  .

·         Positive social media comment and local media reporting

·         Positive report from Local Medical Committee and no disquiet being reported to them by patients.

·         Positive reports from local A&E Departments consultant that cases referred from 111 have been appropriate.

·          No formal complaintsor adverse incidents

 

Planned improvements

 

The Wales Audit office are conducting a review of out of hours across Wales and the NHS Delivery Unit will be looking to support the NHS in delivering the recommendation from this report in early 2017.

 

An all-Wales GP OOH Task and Finish Group is to be established. The Group will be chaired by John Palmer, Executive Director of Primary Care, Cwm Taf which will look to ensure that the service is robust and that the implementation of the 111 service will provide an integrated and consolidated response going forward.