What are your main reflections and learnings from the pandemic to date, on the challenges faced by the ambulance sector and how trusts have responded?
I will start off by saying how proud I am of AACE, NWAS and all our staff across the ambulance sector, as well as all the volunteers, who have worked so hard and tirelessly over the last eight or nine months to deal with the COVID pandemic response. This has been the biggest challenge ever faced by the ambulance sector, the whole of the NHS and the country. I have been in the ambulance sector for nearly 30 years and I didn’t think for one minute we would be dealing with a pandemic on this scale.
My main reflection has been the speed with which the ambulance sector was able to increase its level of resourcing, for example our 999 and NHS 111 contact centres and our operations out in the local community. In the early days, the 999 and 111 call volumes increased significantly as COVID started to become prevalent in the community but, as lockdown took effect, 999 activity reduced considerably. This was unsurprising due to fewer people moving about – this meant fewer accidents, road traffic collisions and fewer alcohol-related calls.
I was very impressed at how the ambulance sector was able to recruit and train additional staff and volunteers to support frontline operations. In my trust, we were able to recruit an extra 450 staff.
I was pleased to see how the ambulance sector came together to share learning and divert resources across the country as needed. I know that other ambulance trusts were able to support London during peak demand through the national ambulance coordination arrangements.
Are the national coordination arrangements still ongoing?
We have certainly got them in place, and they will continue into the winter. This allows for demand, activity levels and resources to be monitored and coordinated across the ten ambulance trusts and allows us to be much more responsive to pressure points.
Another thing that worked well was the AACE national groups of medical directors, HR directors, operations directors and so on. These groups kicked in as part of the national command and control arrangements and were able to lead some changes and policy directions nationally on behalf of the ambulance sector. For example, we were able to work with NHS England and NHS Improvement to develop sector-specific guidance on infection prevention and control.
Do you think the experience of COVID has accelerated the role of the ambulance sector in system working?
I would like to think it has, and this has certainly been the case in the north west. One of my ambitions as AACE chair will be to work with chief executive colleagues to see what more of a role we can play in that system leadership role.
The early adopter sites for the NHS 111 First model are a great example of where we’re seeing this in practice. The sites I am involved in are very much focused on system working and design to increase NHS 111 capacity and manage the booking process effectively.
We’ve also seen it in the ambulance sector’s ability to put in place significant command and control arrangements 24/7, locally, regionally and nationally. As regional providers, ambulance commanders and leaders have had to work across multiple local resilience forum structures, sustainability and transformation partnerships (STPs) and integrated care systems (ICSs) and have had to do so for some months now.
What are your reflections on how ambulance trust leaders have worked together during the pandemic and what are your priorities as AACE chair?
Trust chief executives have continually worked collaboratively through AACE, as well as with our other director colleagues, and we will continue to do so. As AACE chair, my priorities are as follows:
- making sure the sector is prepared to tackle COVID in the winter – this will be a major challenge for all providers
- looking after the mental health and wellbeing of our staff and volunteers
- system leadership and the role that ambulance trusts can play to support this across regions
- digital capability within the ambulance service – for example, tracking vehicles, electronic clinical records, command and control systems and video consultations
- improving equality and diversity in the ambulance sector.
I think we also need to make it easier for patients and their families by having fewer access points to care – 999, NHS 111 and GP – and explaining what the offer is across these access points. If we also look at public sector finances, why would we have multiple workforces, estates and IT platforms across some NHS providers which mean inefficiency, less resilience and more opportunities for things to go wrong? An integrated workforce, digital platform and estate is the right thing to do. At NWAS our strategy is about having one triage platform which allows you to have integrated estate and digital systems with a workforce that can work flexibly across the NHS 111 and 999 services.
What are the examples of innovations or beneficial changes developed during the pandemic that have stood out for you?
AACE has developed a publication setting out what went well and the requirements for sustaining these changes for the future. Ambulance trusts will also be undertaking a lessons learned review. As the new chair of AACE I am taking the opportunity to review our strategic priorities and to take into account learning from COVID.
An example of a positive change has been our ability to retrain our patient transport staff, training them to work alongside paramedics and emergency technicians and increase our 999 response capacity during COVID. This gave us real flexibility and surge capacity in those trusts with patient transport services.
Something else we may want to keep in the future, particularly in our NHS 111 service, is the way we were able to deploy nursing, paramedic and medical students to support our NHS 111 and 999 emergency operation centres.
These workforce-related changes will also help to inform our future work with local STPs and ICSs on our staffing model and engagement with primary care networks (PCNs) on rotational models.
Another change is around video consultations, particularly in the 999 and NHS 111 centres, to increase our ability to safely keep patients in their local communities without the need to send an ambulance or take them to emergency departments. A mixture of face to face and video meetings is something which we want to keep and upscale in the future.
Do you have any reflections on supporting staff and wellbeing?
Staff and volunteers have found the last eight or nine months very difficult. We are going into unknown situations and staff are putting themselves at risk. Many people are worried about bringing the disease back with them to their family and loved ones. I don’t think the ambulance sector is unique in this respect. Other parts of the health and care sector will continue to be worried – it’s not just the frontline staff and volunteers but also the corporate teams, procurement, fleet, IT to name but a few and the senior leadership teams and managers who have been working flat out during this pandemic.
In the north west we have five local resilience forums all running concurrently with one another at strategic, tactical and operational levels as well as the many other NHS cells and our own internal national, regional and local command and control structures in place, which has taken its toll on leaders.
We need to continue with the health and wellbeing support we have provided for staff and volunteers and keep this enhanced support in place. Some of the initiatives have included welfare vehicles, enhanced occupational health, peer support and counselling. In the north west, we have been doing additional things like bespoke podcasts around stress, anxiety, sleep and nutrition and holding Facebook live sessions to support staff. We have also extended our mental health support. Some trusts were using therapy dogs before COVID and are planning to bring them back post COVID. There is never enough you can do and we will continue to review, listen to our staff and learn going forward.
Looking ahead, what support do you think the ambulance service needs from national and regional bodies to help manage COVID-related challenges and navigate the return to near-normal levels of non-COVID healthcare?
We need a consistent seat at the table nationally, regionally and at system level as we have a huge contribution to make. I would like to see the regional and national teams ensuring that the ambulance service takes a more prominent role in the urgent and emergency care space and delivering further integration of NHS 111, 999 and patient transport services. You can see this is happening in some regions.
We are heading into unknown territory and a busy period. I think that if we are able to access some of the same support we had during the earlier stages of the pandemic and are able to put resources in the right place, it could help the ambulance sector get through winter. All ten ambulance trusts were able to turn their performance green in May to early July but now performance has started to become challenged again in a number of ambulance trusts. This begs the question of whether the national and regional bodies need to review how ambulance services are commissioned and resourced.
Are you getting a sense that activity is returning to a pre-COVID level or is activity still different?
It did start to return to normal levels but is now increasingly busy again with the type of activity you would see at this time of the year. So that coupled with flu and COVID will mean we’re in for a busy winter.
What are the additional challenges that you’re likely to face over the winter period?
Some of it will be the demand placed on the ambulance and NHS 111 services. In the north west, we are planning for at least a 20% increase in call volumes and we’re working with our system partners on opening up further the directory of services to make sure we can book patients to emergency departments or sign post them appropriately to other parts of health and social care.
We still have some of the same challenges around workforce. In line with national guidance, some staff are shielding, self-isolating or are taking additional precautions due to being in vulnerable groups. Another challenge includes the equality and diversity within our workforce and how we continue to keep our Black, Asian and minority ethnic staff staff and volunteers safe. We also recognise that we need to continue to do more to support our local Black, Asian and minority ethnic staff communities.
Have you been part of the NHS 111 First pilot?
A number of NHS 111 providers have gone live recently with NHS 111 First early adopter sites. We went live recently in the North West in Blackpool and Warrington and will be keeping a close eye on what the data from the pilot are telling us. The hope is that these pilots will show the 111 first approach to be an effective way of supporting patients to access the right care as quickly as possible and help us to better manage the ever-increasing demand for NHS services.
Ambulance trusts including the north west that run both 999 and NHS 111 are also speeding up how they integrate their 999 and NHS 111 services and working with commissioners to commission these services in a more strategic joined up way. It’s a complex picture currently, with one contract for NHS 111, one for 999 and different contracts with different clinical commissioning groups for patient transport. They all have different start and end dates with different lengths of contract duration.
What has struck you most about the challenges you have seen during the pandemic and the ways colleagues have coped. Do you have any further personal reflections?
I think it has been how everyone across the organisation has come together in the best interest of looking after patients and colleagues. What really struck me was how everybody dropped what they were doing and made themselves available to provide support and take on additional roles and functions that they wouldn’t normally do. This can also be said for how providers and others have really come together to break down organisational boundaries, overcome blockages, worked together to open up new alternative pathways for patients and shared workforce to deal with some real pressure points.