Site 1
Geographical coverage of services
Site 1 currently serves populations across six counties. Within the region there are 11 acute trusts and seven mental health trusts as well as a large number of general practices and community health service providers. The six counties and the organisations within them each have a separate identity, which creates complex fulfilling requirements.
Population
The region covered by site 1 includes areas of severe deprivation. The population is growing and the number of elderly in the population is also increasing.
Restructuring of services
This research project was carried out during a time of restructuring at the site. Plans include the reduction in the number of regional divisions from five to three. The reported rationale for restructuring is to reduce unnecessary costs as well as increase quality of care. The five divisions are reported to no longer serve a useful operational purpose yet perpetuate reported cultural divisions that are historically linked to the five separate county ambulance services.
In carrying out the plan, the trust aims to disestablish one line of management (around 46 posts) as well as the general manager role. An important factor behind the restructuring plans is the loss of the patient transport service contract, which will impact on future resource planning. In addition, many of the
ambulance service bases are reported to be outdated and for much of the time vacant. Therefore, a larger number of smaller bases called tactical deployment points, supported by 13 hubs (four to five in each division), are planned. The small bases will provide staff with essential amenities to support standby duties such as toilets and drink facilities. Hubs will provide space for meetings and will have Make Ready facilities. Make Ready facilities include a team that carries out cleaning of vehicles, with deep cleaning of interiors to comply with infection prevention and control indicators. The team also check that the vehicle is serviceable before the shift begins and that it is carrying the correct (tested) equipment and that it is stored in the correct way.
Service delivery model
Currently, there is one level of response to all types of call, regardless of the clinical requirements. At least one paramedic is required for each attendance, either responding alone (paramedic or ECP) or assisted by a technician or an ECA. The new model proposes three levels of response, to be implemented by 2014: l Urgent care ambulance crewed by two ECAs, available for urgent transport in cases in which a
paramedic is not required. The vehicles will all have bariatric capabilities. The crew will still be able to respond to emergency (category A) calls in the first instance if they are close to an incident.
l A paramedic and ECA/technician in an ambulance or a sole responding paramedic in a fast response vehicle. In both cases the paramedic will assess the case and make decisions about the most
appropriate pathway. In both cases it is envisaged that this service will form the core response to 999 calls.
l An ECP, following assessment by the urgent care hub and a subsequent decision that further assessment is required, to potentially allow the patient to remain on scene or be referred to community health care. ECPs will still be able to respond to any call category but will focus on admission avoidance.
Divisional operations structure
Each division has a service delivery manager who oversees the operational support managers and paramedic team leaders. A clinical quality manager is responsible for delivering clinical strategy against clinical indicators within the division. Operational support managers can oversee groups of ambulance stations or one station and are responsible for managing staff and budget issues. Paramedic team leaders facilitate personal development as well as managing staff and their working arrangements. They also carry out operational roles when demand is high. Restructuring will disestablish 144 paramedic team leader posts and replace them with 90 team leaders and 30 locality team supervisors. Further new roles resulting from restructuring include a divisional director, a head of performance, a paramedic consultant and a service improvement manager for each division.
Strategies
Risk management
The risk management policy is reviewed by the trust board once a year. Potential risk is registered at local and divisional levels. A risk evaluation model is used to score risk for its potential impact.
Staff profile
Emergency operations centre
The EOC includes non-clinical health advisors who use the AMPDS to assess incoming calls. A clinical hub is staffed by qualified paramedics and nurses who assess non-life-threatening calls and provide self-care advice or referral to other health-care professionals. Clinicians also provide a telephone clinical assessment and advice service for patients who do not require admission to A&E.
Operational staff
As well as employing ECAs, paramedics and ECPs, three consultants paramedic posts were appointed during the course of this study. Site 1 supports three air ambulances in the area. The HART comprises 40 members of staff. Site 1 is also supported by a range of voluntary community first responders (CFRs) across the region.
Documentation and communication
Site 1 was the first ambulance service in England to roll out the use of the ePRF in one of its divisions in 2011. It is now in operation across all divisions, although paper PRFs are also used.
The Directory of Services was recently introduced to allow front-line staff access to information about alternative pathways in the local area.
Site 2
Geographical coverage of services
Site 2 covers a geographical area of approximately 6000 square miles, across five regions. The area includes a total of 62 ambulance stations and seven administration/training centres. The area includes remote moorland and coastal areas as well as towns and cities.
Population
The population across the area is diverse, with many of the major towns and cities reported as having higher deprivation levels than the average for England, although some have relatively low levels of deprivation. The area has the third most ethnically diverse population in England. Site 2 reports a Muslim population that is twice the national average according to the 2001 census. A CFR scheme has been initiated to address the tendency towards late reporting of incidents in this population. Around 40% of site 2 emergency services are used by the elderly (>65 years).
Alternative referral pathways
A number of referral pathways are being developed as an alternative to conveyance to A&E. These include end of life, mental health, social care and alcohol/substance misuse.
Staff profile
Emergency operations centre
The EOC includes non-clinical health advisors who use the AMPDS to assess incoming calls. Recently, a clinical hub has been developed that is staffed by qualified paramedics and nurses. Clinicians assess non-life-threatening calls and provide self-care advice or referral to other health-care professionals.
The clinical hub also provides clinical information and advice to ambulance crews on the road, for example crews may require information about a specialist pathway in an unfamiliar area.
Operational staff
Site 2 employs nearly 1900 paramedics, EMTs and ECPs across the region. ECPs work in a number of areas; over 500 referrals to ECPs were made in the year 2012–13.58
The site introduced the ECA as a new role within this service during the course of this study.
The air ambulance service currently has two charity-funded helicopters based in the area. A HART has been in operation since 2009.
To improve service delivery for residents in rural areas, a pilot scheme is in progress to assess the use of community paramedics working within a local general practice in a rural area. The paramedic works alongside the general practitioners (GPs) and district nurses.
Thirty BASICS doctors are currently supported by the service and 960 volunteer CFRs work within the site. Documentation and communication
Site 2 uses paper PRFs to record attendances. Up to 20,000 forms are completed each week across the trust. Forms are stored securely at each ambulance station before collection and delivery to one of five clinical business units for electronic scanning into the OnBase system (ProcessFlows Ltd, Winchester, Hampshire). The system allows key words to be searched within the documents so that clinical audit can take place.
Site 3
Geographical coverage of services
Site 3 covers an area of 3600 square miles; it is therefore smaller than the two other sites yet the number of calls that it receives per year is comparable. The population covered is around 4.3 million. The trust operates from 70 ambulance stations.
Service delivery model
Site 3 is developing a front-loaded service model which ensures that initial patient assessment is carried out by an allied health professional, preferably with advanced training (such as a CCP or a PP).
The trust makes clear distinctions between critical care (emergency–convey) and primary care (urgent–referral) elements of pre-hospital care. Practitioner roles reflect this distinction. The ideal is that these two elements would function seamlessly to provide overall pre-hospital care.
In site 3 the ECP role is not recognised as the role is not regulated by one professional body. Strategies
Risk management
The trust claims to aim to integrate risk management into other trust functions. Locally identified risks to service users, staff or other stakeholders are entered onto a Directorate Risk Register and trust-wide risks are entered onto a Corporate Risk Register. The register is reviewed every 2 months by the Risk Management and Clinical Governance Committee, every 3 months by the Audit Committee and every 6 months by the board to ensure compliance with the CQC.
Staff profile
As of March 2013, site 3 employed whole-time equivalents of 318 EOC staff, who commenced utilisation of the NHS Pathways triage system in 2011. The system was developed to provide links to a broader range of health and social care pathways. It includes facilities for clinical assessment and patient call backs, as well as‘hear and treat’.
Site 3 employs 1728 operational staff. Of these, 51% hold professional qualifications, including specialist paramedics, managers and team leaders, and 49% are technicians and support workers. The service employs a HART comprising 73 members of staff.
The role profile includes ECAs, emergency support workers, ambulance technicians (although this role is now being phased out), paramedics, PPs, CCPs and a HART. The service is also supported by 500 CFRs. Documentation and communication
Site 3 is implementing the procurement of the ePRF system to replace paper PRFs.
The site is developing IBIS to improve clinical information sharing. IBIS has three elements:
1. It holds information from specialist community resources regarding patients with long-term conditions. The information is shared with ambulance staff, triggered by a 999 call for that patient.
2. It collates information about non-conveyance to hospital and can assist in more effective management of care for regular callers.
3. Clinical summaries of care can be forwarded to GPs following an episode of care delivered by a PP. PHASE 1 FINDINGS: MAPPING THE SYSTEM