England’s ten ambulance trusts occupy a unique position in serving large geographies, each spanning footprints of upwards of 30 CCGs, or ten or more Sustainability and Transformation Partnerships (STPs) and Integrated Care Systems (ICSs). We recently spoke to eight leaders from seven of the ten ambulance trusts to hear their experience of engaging with STPs, ICSs and place-based care. Here we share ten quick reflections from those conversations.
- Ambulance trusts are involved at multiple points in the patient pathway. While STPs and ICSs focus on transformation at the level of place, the position ambulance services occupy within the wider health economy and the large geographies they cover means that they are often better placed to engage at the system level. Their involvement at multiple points in the patient pathway means they need to be engaged closely at a local level, but they can equally offer a strategic overview of what is going on at a system level, providing the much needed context for place-based care.
- It takes time and resource to fully engage across the footprints which ambulance trusts cover. System working requires a new investment of leadership time and energy for all trusts however, the fact that ambulance trusts cover numerous STPs has prompted them to devise strategies for ensuring they can play a role at every table. One chief executive described a week in which the trust’s chief medical officer had 38 hours of such meetings scheduled. Many trusts have allocated responsibility for each STP/ICS to a member of staff with sufficient authority (such as an executive director) meaning no single colleague is spread too thinly to build a meaningful relationship with system partners in different STPs/ICSs.
- Conversations vary according to the maturity of the STP/ICS. Often, the degree of engagement ambulance trusts have within an STP, depends on the maturity of that partnership, and how far conversations within the STP have progressed around transformation of care. Where relationships are good, ambulance trusts find space to be involved in the clinical work taking place across diverse work streams, including in primary care, social care, and public health. Elsewhere, relationships are still emerging and conversations tend to focus more on operational challenges with the individual system partners more prone to retreat into organisational siloes when they need to focus on meeting regulatory requirements around performance.
- Ambulance trusts are adapting their models to suit the new landscape. Operating services across a number of STPs inevitably means change – to both services and care pathways. Ambulance trusts are taking stock of the diverse approaches to system working across their patch and adapting their ways of working in a pragmatic way, to suit the needs of individual systems. In some areas, ambulance trusts are working with emergency departments on their patch to support improved patient flow, where possible, by diverting patients towards A&E departments with more capacity. Where acute care reconfiguration has taken place, ambulance trusts are fluidly adapting their resource planning to take account of the resulting change to patterns in resource deployment and conveyance times.
- Developing and supporting a flexible workforce can benefit all system partners. Initiatives to rotate advanced paramedic practitioners into GP practices can support ambulance trusts to reduce conveyance rates and 999 demand from GPs, as well as pre-empting people’s need for urgent and emergency care at home. As well as this, situating advanced practitioners, GPs, midwives, mental health nurses, pharmacists, dentists and even social care staff within ambulance clinical assessment centres, can both ensure that patients are advised by the right person first, free up paramedic time for the most urgent cases, and equally can alleviate demand on those community teams at the point of access. But it is important that this doesn’t happen to the detriment of staffing in services that need specialist staff.
- Ambulance trusts can help systems to embody the ‘no wrong front door’ principle. Ambulance trusts are often the first port of call for many patients who need support, and they sit at the centre of the array of pathways a patient could ultimately follow on their journey through the health and care system, helping to identify the most appropriate one depending on the patient’s needs. They can create a continuous thread through the health system, acting as the ‘integrator’, to ensure a patient reaches the right service regardless of who they contact first.
- Ambulance-specific technical infrastructure and expertise can contribute to system-wide innovation. Ambulance trusts take an interest in contributing to development not just on clinical pathways, but at the more strategic level on IT, digital transformation and workforce. They are pushing the envelope in terms of the value they can add to the integration landscape, not just in improving clinical pathways but at the strategic level, on IT, telephony, and multi-disciplinary workforce deployment.
- Systems can learn from ambulance trusts’ experience of operating at scale. One of the key challenges around integration is the question of how to scale up small initiatives to achieve efficiencies on a larger scale. With their experience of juggling numerous pathways, and an oversight of place-based practices across their patch, ambulance trusts can bring their expertise and diverse examples of innovative practice to system working.
- Knowledge and experience of supporting people close to home. A key focus of integrated care is the ambition to provide patients with the care they need as close to home as possible. Ambulance trusts meet those patients in their communities and homes and using ‘hear and treat’ and ‘see and treat’ models, have a key role to play in keeping people out of hospital wherever possible.
- Close local and system-level relationships are key. If integration is about building relationships and clear lines of communication, ambulance trusts have much to offer in the way of leading this development given their remit in navigating complex and diverse care pathways at the system and neighbourhood levels – both taking patients to hospital and treating them at home. Ambulance trusts are experienced in connecting patient with falls clinics, mental health services and social care services – a cornerstone of place-based integrated care.
In the words of one chair, ambulance trusts can act as ‘the integrator’, connecting services at the level of place as well as across a system, and coordinating patient care across pathways, from ‘hear and treat’ services, treating patients within their homes, as well as conveying patients to hospital when necessary and sometimes taking them home via patient transport afterwards. For this to be effective, ambulance trust leaders require a seat at every table. In exchange, they can contribute a full and diverse skill set and myriad relevant experiences to help progress integration and system working.