Why is this important?
Digital transformation remains a key enabler to service improvement. New digital ways of working can improve clinical outcomes, patient safety, the user experience of both patients and staff, and staff engagement more broadly. What is more, successful transformation can yield financial efficiencies, either through directly releasing savings, or the avoidance of ‘failure demand’ – that is, the cost created by poorly designed services that create pressures elsewhere in the system. Digital transformation, and the more effective use of data, also underpins the integration agenda. For ambulance trusts covering several ICSs and working with every part of the health and care sector, the gains will be significant: better service coordination and population health management, a reduction in avoidable waits and better response times.
The ambulance sector has traditionally been at the forefront of digital developments. Long before the pandemic, service delivery often involved remote care, with ambulance staff equipped with the digital skills and technology to carry out their jobs. This has been acknowledged in the Carter review, which noted that the adoption of new digital technologies has been a key driver for reducing conveyance rates to hospitals (NHS England, September 2018). The experience of the ambulance sector’s three global digital exemplars also demonstrates the progress made by ambulance trusts which have put digital innovation at the core of their services. Indeed, the nature of ambulance services has led to innovations that other organisations have since adopted, such as using digital technologies to connect staff with the relevant expertise, advice and guidance.
The response to COVID-19 has accelerated these digital ways of working. Better sharing of medical records between ambulance trusts and other health and care organisations has improved and quickened clinical decision making. Collaboration between ambulance services and secondary care providers enabled paramedics to provide care to COVID-19 patients remotely, reducing unnecessary admissions and virus transmissions. New innovative ways of working, such as 111 First, were rolled out nationally and supported by cloud-based digital software to ensure seamless clinical handover for patients who needed to visit ED.
How does it work?
The nature of ambulance service provision – 24/7 care that is delivered as a responsive, connected service – has meant that many ambulance trusts have long placed digital at the heart of their long-term strategies. The sector has often been best placed in terms of interoperability, telemedicine and emergency patient flow.
The global digital exemplar (GDE) programme has been instrumental in driving some of these initiatives, examples of which include establishing live-link video capability with care homes, automating cumbersome processes related to ambulance dispatch, developing a simulator to be able to model impacts of planned system changes, and streamlining the way ambulance systems digitally pass patient information to hospital and urgent care systems. The digital aspirants programme is looking to build on some of these successes although many ambulance trusts will now be seeking to work more closely with their ICS partners to drive local innovations.
The pandemic accelerated much of what was already underway in the sector: closer working between ambulance and other health and care partners, a streamlining of priorities and empowering of frontline teams to get on and deliver innovations. As the sector looks to support broader NHS recovery efforts, trusts continue to stress the importance of digital transformation as an enabler rather an end in itself. Digital is becoming more integrated into wider corporate strategies and ambulance trusts are looking to invest in people and skills, as well as digital technologies. Because of this, digital is no longer seen as the preserve of the IT department – it is now everyone's business.
What needs to happen?
Building on the progress made during COVID-19 will require greater access to both capital and revenue funding. As highlighted in NHS Providers' report, Rebuilding our NHS: why it's time to invest, a survey of trust leaders revealed the most commonly cited capital priority or opportunity was investment in digital and IT (67%). In the ambulance sector, a better capital settlement could enable trusts to invest in digital transformation to improve resilience and responsiveness, for example through streamlined and interoperable computer aided dispatch systems, telephony and triage tools. Such systems represent an investment of many millions of pounds which has not been afforded to some trusts in recent years. This needs to change if the ambulance sector is to be truly “digital first” by 2029, as set out in the long term plan.
Revenue funding is also needed as digital solutions increasingly move to a blended funding model (including software as a service arrangement). Upfront digital investment now needs to be matched with an ongoing revenue commitment to pay for IT developers, software licensing and the training/educational needs of existing staff. Ambulance trusts now looking to adopt cloud first strategies must also move away from on-premises data centres, which will represent an additional revenue commitment. So while capital funding is important, ambulance trusts must also have access to sufficient revenue funding to maximise its digital investments.
Some ambulance trusts continue to face a significant challenge in managing legacy IT systems, with infrastructure out of support or out of contract. These systems represent a cyber security risk but also impact patient care with slow sign-ins and IT outages. Addressing these IT backlogs will require significant resources and time, and benefits realisation, at least in the short term, will be difficult. Trusts need this foundational infrastructure in place before they can consider more advanced digital transformations, such as automation or AI.
National funding arrangements available for ambulance services could be more transparent and consistent. For example, while there were three ambulance GDEs, so far only one ambulance trust has been announced as part of NHSX's digital aspirant programme. Ambulance trusts have fed back that the bidding process for some national schemes can be cumbersome and overly bureaucratic.
It's also clear a one size fits all approach doesn't work for national funding, with variation in terms of capabilities, broader digital maturity, financial sustainability and variation in service delivery. At a system level, ambulance trusts face an even more complex environment, having to agree digital priorities and sign up to transformation plans across several ICSs.
It is positive that a new ambulance data set is in development, with the aim of providing an improved, consistent level of detail about how ambulance services respond to and treat the thousands of calls that are received every day. The new data set will be particularly important in understanding how and why people access UEC, which should help to reduce pressure in the system, support the tackling of health inequalities and improve patient outcomes, safety and experience. An important part of the initiative will be ensuring better linkage to other resources, such as the emergency care data set, in order to understand the patient outcomes associated with ambulance service interventions.
Where is it happening?
Yorkshire Ambulance Service NHS Trust
Frailty response line
During the pandemic, the Hull and East Riding frailty response line was set up by the YAS to provide ambulance clinicians, along with primary and community care staff, with support, access, and information to:
- reduce unnecessary admissions to A&E for frail patients living at home or in a care home
- provide the right treatment, in the right place based on patient choice
- aid clinical decision making to improve care decisions.
A team of geriatricians, GPs and advanced nursing practitioners run the careline seven days a week, twelve hours a day. More than 1,300 patients were supported during the first wave of COVID-19. This service has been important during the pandemic as it prevented suspected COVID-19 patients from entering acute settings.
YAS saw their conveyance rates for patient attended by a paramedic to its lowest ever level, and there has been an overall reduction in A&E attendances and emergency admissions to the local acute trust. Patients now receive care in the right place, at the right time, with direct access to specialist support and the development of patient centred care and treatment plans.
West Midlands Ambulance Service University NHS Foundation Trust
Right place, first time: direct referral to frailty SDEC
Older and frail patients account for 5-10% of all those attending EDs, and 30% in acute medical units. During the pandemic, older and frail patients remained a high portion of those conveyed by ambulance, but had increased anxiety around attending hospitals due to fears of catching COVID-19.
The South Warwickshire NHS Foundation Trust (SWFT) knew that there were missed opportunities for providing care closer to home for these patients, so decided to redesign the available clinical pathway. This redesign gave paramedics access to advice, and direct referrals to the frailty SDEC. This enabled patients to access the right care first time, without conveyance to ED.
The model has now been enhanced and embedded with the provision of direct phone access to the multi-professional frailty team. This enables paramedics to assess older and frail patients more effectively, increasing their ability to support patients at home or to convey them directly to the right place for care. By reducing unnecessary steps, wait times are reduced, and patient can be supported on a SDEC pathway where appropriate.
The SWFT frailty team is cross- workforce – geriatricians, nurses, and therapists, who all worked together to embed this learning to redesign the pathways in the West Midlands Ambulance Service University NHS Foundation Trust (WMAS) more widely. WMAS paramedics can now access the frailty team through 'consultant connect', a service funded by the clinical commissioning group (CCG) to provide direct remote access to advice and guidance from geriatricians. Giving access to the live electronic patient record within the ambulance service to all relevant staff means that paramedic assessments can be viewed by the geriatricians on consultant connect. This has led to more informed decisions about care, made in partnership with the patient, carers and the frailty team.
WMAS' work in this area has produced positive benefits for patients, staff, and the system, with an increase in patients treated as SDEC (with 'zero-day length of stay'), and a decrease in the average length of patient stay from 14 to 4.5 days, whilst sustaining a 95% ED performance.
Spotlight on NHS 111 First
All ambulance trusts providing NHS 111 now provide the 111 First option.
Below are some examples of how this is working:
South Central Ambulance Service NHS Foundation Trust
The beginning of the pandemic saw more people arriving in ED, placing a significant strain on services and also increasing the risk of COVID-19 transmissions. South Central Ambulance Service (SCAS) collaborated with Portsmouth Hospitals University NHS Trust to develop a new 111 First pilot system. This has given patients the ability to book directly into the ED via 111.
The scheme has established a new GP-led CAS and introduced a new electronic appointment booking service. Patients are clinically validated, with those who need it given a slot to attend ED while others are directed to more appropriate and suitable care. SCAS supported a rollout of their patient management software, Adastra, within the acute setting to ensure seamless handover of patients.
With the pilot a success, 111 First was rolled out nationally over winter. Feedback from patients has been positive, and to date nearly 43,000 appointments have been made using the SCAS 111 First Service, avoiding the need for patients to wait in crowded ED rooms.
West Midlands Ambulance Service University NHS Foundation Trust
Anticipating an increase in 111 calls due to the 111 First model, WMAS put several services in place to support patient flow and access to care:
- ED direct booking, which supports acute trusts in managing patient flow during periods of increased activity. Direct booking encourages patients to call 111 before taking themselves to an ED, meaning that more patients can be referred to other services or given home management advice, as appropriate. WMAS' service allows for timed appointment slots to be booked, whilst sending the patient's electronic record to all West Midlands EDs, speeding up access to care.
- Clinical validation for category three and four incidents, as well as emergency treatment centre (ETC) incidents. Whilst this places more initial demand on clinicians, it has resulted in much smoother patient flows. In June 2021, 86.77% of category three and four incidents received clinical validation, with 54.5% of patients receiving a different outcome, significantly reducing demand on emergency resources. In the same month, 34.11% of ETC incidents received clinical validation, resulting in 9.53% of patients triaged through 111 being referred to an ED.
- Video consultation software to support clinicians to provide enhanced face-to-face clinical triage. Whilst this is dependent on the patients' ability to access and use appropriate technology, a pilot trialling the 'AccurRX' software has been completed, and provided proof of concept. WMAS now has video consultation capability for all clinicians across the IUEC, covering both 111 and 999 functions. Staff feedback is being monitored with short post assessment surveys and has so far shown positive responses from all clinicians.
London Ambulance Service NHS Trust
LAS has implemented a 111/999 and Barts Emergency Access Coordination Hub (BEACH) integration programme. This helps to coordinate access for patients requiring secondary UEC.
BEACH helps to coordinate secondary UEC for patients who do not require immediate conveyance or referral to ED, providing a greater range of alternative pathway options – this may include remote clinical assessments and arranging appointments, or referral to an out of hospital team including a community emergency medicine resource. This enables patients to access care before attending an ED via conveyance from 999 or referral from 111. As of May 2021, 27% of 111 patient referrals to BEACH were managed without requiring attendance at ED. The implementation of this collaborative project has improved ED flow and wait times, and the project is now assessing any unintended impact for 'on scene time' with ambulance crews and whether patients could have been referred to alternative pathways directly by LAS clinicians.