South Central Ambulance Service NHS Foundation Trust
South Central Ambulance Service provides 999, 111 and patient transport services to a population of over 4 million people across six counties. Will also sits on the NHS Providers board, the Community Network board and leads nationally for the ambulance services in England on mental health issues, as well as being a member of the crisis care concordat steering group and the Mind blue light programme steering group.
My perception of community services is that there’s a range of custom and practice in operation, but I see a lot of variation across the community providers we work with. There are those who have done quite a sophisticated job of mapping their resources, capabilities and demand and creating a contact centre, a hub, a single point of access model which is fairly similar to the ambulance service model. Then you get others that are operating completely distributed models, which seem much more based on traditional custom and practice and a lack of data.
When I talk to community providers about our operating model, they see the obvious benefit but there’s something holding them back and I can’t quite put my finger on it. I think they’re rightly a bit nervous about staffing, because the ambulance sector has pushed its staffing model almost to breaking point in the past and adopted operating models which are completely 24/7 in terms of matching rota hours to demand. Becoming one of the most responsive services available to patients increases demand even further.
An operating model built on teams
In terms of efficiency, we were driving a model which increasingly pushed a relatively unsustainable pattern of rotas into the working life – shorter rotas and then longer rotas and staggered rotas to match the peaks and troughs of demand and iron out under-utilisation. Then we’d also asked staff to operate as lone workers as a part of their role. We’ve spent the last couple of years rowing back from that, because we’ve seen a huge exodus of staff and a lot of issues in terms of wellbeing, resilience and sickness rates. I think we’re in a better place now and a lot of work is going on around trying to improve the lot of ambulance staff.
In terms of efficiency, we were driving a model which increasingly pushed a relatively unsustainable pattern of rotas into the working life – shorter rotas and then longer rotas and staggered rotas to match the peaks and troughs of demand and iron out under-utilisation.Chief executive, South Central Ambulance Service NHS Foundation Trust
It continues to be a risk that people get disconnected from the organisation and colleagues – every minute of the time they are working they are on their own or with one crew mate, patient-facing in the community, and you’ve lost that contact with them. You need to be quite careful to build that contact back in. There are operating rules that you need to define – things around meal breaks, end of shift overruns, shift length. We’ve been looking more recently at fatigue, particularly with the length of some of our shifts and how busy a shift is. We have piloted staff wearing Fitbits, enabling us to measure their levels of alertness when they are at work, particularly during the night shift. There’s quite a lot of evidence around fatigue and safety in safety-critical industries and you can design your roster patterns so you can make sure you’re within a tolerance level of what’s safe. This has helped us to shift the engagement with staff around rota design to find a win-win in terms of patterns.
As far as supporting a disparate workforce, what we have done is create a model built on teams and ensured we encourage those teams to be strong and effective. You don’t break the team up – you need to have a line manager who’s consistently there and available to support the team in real time and also does the team’s feedback and appraisals. We create regular team time to encourage the team to be a supportive unit – it’s small but non-negotiable in our operating model. We’ve got 138 teams in South Central Ambulance Service and they have half a day three times a year of their own team time which they spend self-directed. Team leaders are completely rostered so support is always there.
Integrated urgent care
Although we provide the NHS 111 service we recognise we can’t provide the entire ‘front door’ that patients need or want because a lot of other organisations have the staff and expertise that need to be incorporated into delivering that effectively. Carving a virtual clinical assessment service (CAS) into a separate organisation potentially disconnects the front end from further referral pathways that naturally sit within community, mental health and primary care services. We’re trying to build a more inclusive offer quickly, which is why our relationship with the community services and out of hospital providers is so important.
We create regular team time to encourage the team to be a supportive unit – it’s small but non-negotiable in our operating model.Chief executive, South Central Ambulance Service NHS Foundation Trust
One of the big areas we’re interested in is integrated urgent care and working collaboratively with all out-of-hospital providers to populate a directory of services. That’s to do two things really – one is to provide earlier assessment and advice for patients presenting, and secondly, to potentially refer patients to other services once they’ve undergone an initial assessment so that they can get more bespoke personalised access. Building an integrated front door and behind that a directory of services that we can book and signpost patients into is a significant part of our service strategy – particularly for those ambulance services that are providers of the integrated urgent care 111 service.
Levels of conveyance of patients to acute hospitals is a real area of focus for our whole system. It can get quite contentious around whether a patient is inappropriately conveyed – it’s a sensitive area because in different settings, with different information and clinical expertise, different decisions might be made, and, in addition to that, organisations (and individuals) have different tolerances to risk. That’s why we need to shift the model so we’ve got trusted advisors and trusted assessors support as early as possible to make decisions. One of the things we’re trying to pursue is to have the ability for any of our staff to be able to access decision support advice from anyone they think they need support from. If, for instance you’re with a mental health patient and the ambulance crew could benefit from more information, expertise and experience from someone in a mental health service, you’d be able to access that in real time. I think you’d get quite a different range of outcomes as a consequence of that model.
Traditionally, a lot of ambulance work – particularly the less acute patients – hasn’t been clearly differentiated in terms of condition and therefore best practice pathways do not always exist. Things like the stroke pathway, the trauma pathway and the heart attack pathway are extremely well-evidence based. Wherever you go in the country now, these clear pathways will be in place, but that’s still quite a small proportion of what ambulance services do. There’s a large amount of undifferentiated urgent demand – for instance for patients with long-term conditions, minor injuries, illnesses and infections, or mental health concerns. In our clinical strategy we’ve got eight or nine groupings in those areas and what we try to do is to work with other providers (the experts) to understand what the best pathway is for those patients – which isn’t necessarily to go into hospital.
One of the things we’re trying to pursue is to have the ability for any of our staff to be able to access decision support advice from anyone they think they need support from.Chief executive, South Central Ambulance Service NHS Foundation Trust
To try and put the right trusted assessment and advice in place when we find patients fitting into those particular cohorts – that’s quite a shift for the ambulance service, which has traditionally been a transport-based service. We now face much more into the community than into the acute sector.
Our primary model of trusted advisor at the moment is through the GP. Where it’s clear a patient doesn’t immediately need to be conveyed, we will try and access the patients’ GP and get trusted advice from them. There may already be a care plan in place for the patient. We do have care plans in place as well – written plans that are loaded into our system for individuals with long term conditions. We also have midwives, mental health nurses, children’s services and social workers available in our contact centres.
One of the things we’ve done to bridge to community and primary care services is to create our own urgent care specialists (paramedics), who deal with minor injuries, long-term conditions and increasingly prescribing. In a way they are reaching into an area that’s more traditionally nursing and community district nursing and that’s helped us to connect up. We have explored some of that with our community providers because there’s a whole resource out there in the community, such as district nurses, that is local, particularly in more rural areas, that could meet the patient’s need where otherwise there’s no alternative but to send an ambulance. A good example is where we now send appropriately trained volunteers to our non-injury fallers and to silent alarm calls for elderly patients. The model we operate there is one where the patient can be assessed by a healthcare professional on the telephone with the volunteer on scene and once satisfied we can discharge without sending a registered healthcare professional. We are perfectly happy with clinically authorising that remotely, from a governance perspective.
One of the things we’ve done to bridge to community and primary care services is to create our own urgent care specialists (paramedics), who deal with minor injuries, long-term conditions and increasingly prescribing.Chief executive, South Central Ambulance Service NHS Foundation Trust
An art and a science
In terms of planning and organising our 999 service we look at call and incident demand, geographically and by hour of the day. You then start to map your route patterns. It’s harder for us to meet demand at certain hours of the day and we would tend to start from a slightly lower base of performance in the morning. It’s pretty advanced planning – based on operational and production management – essentially it’s an engineering production science. You’ve got to ally all of that with the human factors as well. Ambulance services have made a real art of it.
In terms of the scope of 999, 111, primary care and community services I wouldn’t make a distinction between planned care and unplanned care at all, quite frankly. I think there’s just varying degrees of responsiveness in a continuum and it should be planned together and seamlessly integrated. We’ve been having this debate a little bit recently in terms of integrated urgent care and the scope of services that should be included. The future operating model is one lots of service industries moved to years ago, particularly as we look to exploit technology. They don’t make an artificial distinction in terms of what’s planned and what’s unplanned – it’s all about how responsive the service needs to be. Most patient generally have a sense of what responsiveness means and it’s relevant to the context of the situation.