If you are involved in organising – or even just responding to a major public consultation on reconfiguring NHS services, this paper is for you. In part, it arises because of Lord Carter’s recent Report on Operational productivity and performance in English NHS Ambulance Trusts. The issues are probably very similar in Scotland, Wales and Northern Ireland.

Our principal conclusion is that changes and practices in the Ambulance service need to be better integrated into proposals made and dialogues held on major changes to healthcare systems.

1. The role and management challenges inherent in delivering a high-quality ambulance service are often below the radar.

• It takes 10 million calls each year, growing at 4% – 6% per annum
• Ten NHS Trusts serving populations from 2.8m to 8.8m, deliver the service and work largely autonomously with huge ‘unwarranted (Per Carter) variations’ in practice and performance. The potential creation of a National Ambulance service has once again been deferred.
• The service has been changing – from just conveying patients to hospitals to ensuring care and treatment for individual needs. Its three response models are:

Hear & Treat – telephone advice via Call handlers at Call Centres (5%)

See & Treat – treated and discharged on the scene (30%)

See & convey – taken either to an A & E or somewhere else suitable (65%)

• There are four categories of calls:

Life Threatening

Emergency

Urgent

Less Urgent

Response time performance for the first two categories had dropped in recent years, and in 2017 a new set of standards was introduced. In July 2018, eight of the ten Trusts failed to meet the new 7 minute mean response standard for Life Threatening (Category 1) calls. For Emergency (category 2 calls), again eight out of ten Trusts failed to meet the 18 minute target.

• Trusts have serious management challenges with high staff turnover at call centres, a shortage of paramedics, poor sickness records (due in part to violence and bullying from patients etc) and an ageing and increasingly unreliable ambulance fleet.

2. No wonder therefore that when NHS services are reconfigured, public and patients alike feel nervous about centralisation or resource concentrations that suggest more dependency on the ambulance service.

• Time and again, public engagement and consultation staff are surprised how much the debates at public meetings, deliberative events, focus groups or co-production exercises revolve around travel times to Accident & Emergency departments.
• Ambulance Trusts are rarely present at such events and are seldom able to provide facts and figures on response or conveyance performance leaving (possibly inaccurate) anecdotal information largely unchallenged.
• Ambulance services are sometimes blamed for problems that lie elsewhere in the healthcare system. These include avoidable calls, due to poor access to GP services or primary care, repeat calls from frequent users because of poor community services, or, most newsworthy, handover delays when patients arrive at over-stretched hospitals.
• Patients and public are very focused on the actual ‘travel time’ to proposed new sites, but this is frequently only about a quarter of the total job-cycle time for the ambulance call. Debates are lop-sided because of widespread misunderstanding of the total service configuration
• Some of these issues create knock-on effects that impact public and patient trust in the whole-system provision and reduce confidence in the much-advertised ‘integrated’ health and social care service.

3. It would be better if Ambulance Trusts played a bigger role in pre-consultation, options-development and the preparation of consultation papers.

• Over the years, the Institute has seen a great many reconfiguration proposals published in consultation papers. Only rarely do they demonstrate close involvement by Ambulance Trusts.
• Ambulance Trusts often see themselves as consultees, and have been known to make public comments doubting the deliverability of service change proposals. Because they are commissioned by lead CCGs, the degree of service co-design varies enormously. It also makes service changes in the middle of commissioning period less attractive and complicated.
• The creation of Sustainability & Transformation Partnerships (STPs) pose significant management challenges. Note this telling comment:

“Each ambulance trust covers between two to eight STPs, increasing the challenge of building and maintaining relationships with stakeholders, particularly given their relatively small size. One trust calculated that invitations to STP and CCG meetings stipulating executive director attendance would take up over 65 hours in one month alone. STPs and others need to work out effective mechanisms for managing their relationships with the ambulance service.”  (Page 11, Carter Report)

• Where representatives of the public or patients become involved in co-production exercises, they need to have better access to Ambulance managers and planners.
• Both Health Overview and Scrutiny Committees and Healthwatch groups need a better understanding of the Ambulance Services – the challenges as well as the opportunities – so as to better assess and consider proposals for service change.

It has been clear now for many years that if you want to rationalise the provision of NHS services, and deliver better outcomes from fewer locations, a key pre-requisite is to invest in your ambulance service.

The Institute has argued that the better the ambulance service, the greater the likelihood of creating confidence in the system as a whole. This is particularly important in specialisms that are under pressure such as maternity, paediatrics, cardiovascular, stroke and acute mental health. Too many public dialogues become bogged down in detailed arguments about average travel times, with eye-catching headlines such as the well-known, but unproven assertion made during the NHS Calderdale public consultation, that “117 people will die in the ambulance.”

We will be advising our Quality Assurance teams to focus even more strongly on ensuring that clients embarking upon serious reconfiguration of NHS can show that their proposals have been thoroughly developed with the co-operation of the Ambulance Trusts, and that these Trusts, in turn, make their Managers and communications staff more aware of the rigorous demands of consulting the public on changes to our most vital emergency services.

 

Rhion Jones is Founder Director of the Consultation Institute and is available to discuss aspects of this paper with Institute members and others during week commencing Monday 19^th November. Phone Rebecca Wright on 01767 318350 or email rebeccaw@consultationinstitute.org