All ambulance trusts operate across geographies covering more than one STP. This means ambulance trusts have considerable learning to share about operating at scale across larger patient populations and have valuable insight into how changes in services in one STP can impact on those in neighbouring footprints. Operating at scale, however, makes engagement with multiple STPs/ICSs resource intensive for ambulance leaders and often a challenge to be 'at every table'. It is vital that STP and ICS leads recognise the central, coordinating role that ambulance trusts offer and proactively include them in planning for their local health economies.
Developing a sense of place
Although the trusts we spoke to were all keeping a close eye on the developments within the STPs and ICSs they are involved in, and working with system leaders to adapt the way they work to the needs of the changing health landscape, it can be a challenge for ambulance services to engage with all local initiatives at the neighbourhood level. Many of the trusts we spoke to described adapting their approach to the needs of the STP/ ICS both through reorganising the way they deploy staff to engage within the STP, as well as responding to the changing needs of the health service by aligning their own operational plans with the work taking place in systems. To do this, they need early engagement from STPs/ICSs on the activities they need to take into account. For example, an acute reconfiguration that concentrates urgent and emergency activity to fewer acute hospitals on their patch can impact on patient journey times and demand on ambulance resources.
Ambulance trusts have considerable learning to share about operating at scale across larger patient populations and have valuable insight into how changes in services in one STP can impact on those in neighbouring footprints.
Trust leaders mentioned that frontline staff and ambulance crews need to be aware of diverse pathways, as each system is so different. In the pursuit of place-based care, health and care organisations are collaborating to develop new ways of working, and often this means integrating care pathways within small footprints, connecting primary care networks and local community and acute services in a way that streamlines care for local patients.
Ambulance trusts need to integrate their services into each of the local pathways, which can vary from place to place – where there is a lack of consistency, challenges can arise for frontline staff. One trust chair emphasised the need for consideration of how neighbouring STPs can collaborate to agree a unified set of pathways, rather than each individual STP developing their own in isolation. This was seen as having the potential to benefit providers delivering services across a larger footprint and in preventing unwarranted variation.
Managing pressure on resources
All of the interviewees were clear that the process of engaging with an STP or ICS creates considerable demand on senior leadership time and other resources. While STPs and ICSs convene working groups for different areas of transformation taking place locally, the position ambulance services occupy within the wider health economy and their role as a gateway to the health service means that often there is a need to be closely involved at multiple stages along the patient pathway, including primary care, social care, and public health, as well as urgent and emergency care.
In this context, covering more than one STP can mean duplicating work, meetings, and relationship management. For example, one chief executive we spoke to described a week in which the trust’s chief medical officer had 38 hours of such meetings scheduled. Others mentioned the value of STPs’ recognition of the pressure ambulance trusts are under to engage across the many STPs, particularly where existing commissioning for quality and innovation (CQUIN) requirements include STP engagement and to proactively ensure they are not overlooked when they cannot be physically present.
Many ambulance trusts are developing ways of managing this workload internally, by allocating responsibility for each STP/ICS to a member of staff with sufficient authority (such as an executive director) to make decisions on behalf of the trust, meaning that time can be divided between more than one individual and enable bespoke engagement with each STP. Trust leaders identified numerous benefits to this; no single colleague is spread too thin, and it enables the trust to become involved in the more in-depth clinical transformation, and to build closer relationships with system partners.
We’ve changed our operational structure to mirror the STPs, with the view that you get out what you put in. The level of engagement we maintain is resource intensive but our visible leadership across multiple organisations has adapted over many years to meet local needs.
Others, however, identified a benefit to transferring the bulk of their stakeholder engagement from over 20 clinical commissioning groups (CCGs) to a smaller number of STPs, and many described the expertise in managing multiple footprints they have gained from experience of working with large numbers of CCGs as being vital to their experience of integrating into STP working groups.