Agenda item

(To receive a report from Blanche Lentz (Lincolnshire Divisional Manager, East Midlands Ambulance Service (EMAS)) which summarises the key areas of demand and performance within East Midlands Ambulance Service with particular reference to the Lincolnshire Division.  Blanche Lentz (Lincolnshire Divisional Manager) and Neil Scott (Lincolnshire Assistant Divisional Manager) will be in attendance for this item)

Consideration was given to a report by Blanche Lentz (Lincolnshire Divisional Manager, East Midlands Ambulance Service NHS Trust) which summarised the key areas of demand and performance within East Midlands Ambulance Service with particular reference to the Lincolnshire Division.

Blanche Lentz (Lincolnshire Divisional Manager, EMAS), Neil Scott (Lincolnshire Assistant Divisional Manager (EMAS) and Dr John Stephenson (Associate Medical Director, EMAS) were in attendance for this item.

The national performance standards, set for calls to ambulance services, was explained to the Committee as follows:-

·       Red 1 – immediately life threatening calls – 7 minute response time from call received (target 75%) and 19 minute response time for conveying resource to scene (target 95%);

·       Red 2 – life threatening calls – 8 minute response time from call received (target 75%) and 19 minute response time for conveying resource to scene (target 95%);

·       Green 1 – serious but not life threatening calls – 20 minute response time from call received (target 85%);

·       Green 2 – serious but not life threatening calls with no serious clinical need – 30 minute response time of 30 minutes of call received (target 85%);

·       Green 3 – non-life threatening non-emergency call – telephone assessment within 20 minutes of call received (target 85%);

·       Green 4 – non-life threatening non-emergency call – telephone assessment within 60 minutes of call received (target 85%).

The contractual arrangements for the Trust during 2016-17 provided an expected performance against Red1, Red2 and Red19.  With approval from the Clinical Commissioning Groups in the East Midlands, the contractual targets had been set at a lower level than the national performance standards.    Although EMAS was only required to meet response time performance across the Trust as a whole it was stressed that the local expectation was an increase in performance.

Nationally ambulance services were struggling with performance against the national trajectory and standards set and during quarter 3 of 2016/17, the Lincolnshire Division (including North and North East Lincolnshire) did not meet these standards.  Ambulance Services across England continued to struggle with demand and the ability to meet the nationally set targets.  Future changes set by the Ambulance Response Programme nationally would also impact this position as the service migrated to the new method of coding and response by 2017-18.

In relation to Red Conversion rates for Quarter 3 performance at Clinical Commissioning Group level, the percentage was split between red and green calls.  The Red Conversion rate provided a comparison between calls for the very unwell which necessitate a response within eight minutes, compared to calls for the moderately unwell where a response in excess of eight minutes was accepted.

The expected and forecast level to meet national performance standards was 42% of emergency calls and had an acuity level which necessitated an eight minute response.  The increased red conversion rate above the level was a marker of increased acuity of 999 calls.  The red conversion rate had steadily increased to a level of 58% in December 2016 which was significantly above the expected level for efficient delivery of service (42%).  Analysis of these figures showed a steady increase in 111 red conversion over a twelve month programme.

Both Hear and Treat (HAT) and See and Treat (SAT) had increased with a concurrent decrease in See, Treat and Convey, which showed a reduction in conveyance to hospital over Quarter 3. 

Hospital Handover Times for Quarter 3 indicated significant pressure with the highest proportion of one-two hour and two plus delays at Lincoln County Hospital.  It was reported that 6,543 hours in total were lost during Quarter 3 due to turnaround delays at Lincolnshire Division or adjacent hospitals.

The staffing position had improved throughout Quarter 3 with an increase in rostered staff from circa 90% to 97%.  Staff sickness remained the lowest across the wider Trust.

Following the CQC report and identified areas of improvement, the Trust had provided enhanced incident investigation training to Band 6 managers in order to provide a robust service when untoward incidents were reported.  This was also concurrent with increased education of frontline staff on the definition of an untoward incident and what action was required to report them.

Statutory and Mandatory training and appraisals for frontline staff continued to be delivered and the Trust were confident that all would be complete by the end of the financial year.  The skill mix of qualified ambulance staff had also been improved following an extensive and progressive recruitment campaign.

Incident commanders had also undertaken further training at the National Ambulance Resilience Unit to improve and enhance the response to a major incident scenario. 

Plans were in development to move to an all-electronic patient report form service during 2017/18 in line with the forward vision set by NHS Digital. Medicines management compliance had been reviewed and the process changed which had resulted in the lowest recorded number of medication errors across all divisions of EMAS.

The ambulance fleet was continually updated and the Lincolnshire Division had recently taken delivery of 10 new ambulances which continued to provide Lincolnshire with quality and visually upgraded vehicles.

Engagement with partners and agencies continued to build as noted:-

·         United Lincolnshire Hospitals NHS Trust had collaborated on an improved handover process for emergency departments which would continue into 2017/18.  Support was also provided to ULHT during the current temporary overnight closure of Emergency Department services at Grantham Hospital;

·         Lincolnshire Partnership NHS Foundation Trust (LPFT) have worked with EMAS to develop a number of ongoing work streams including the establishment of the mental health triage car which continued to provide assistance to patients where the default of an emergency department was not appropriate for their current condition.  In addition, work was ongoing to develop a frequent caller project;

·         The working relationship with Lincolnshire Community Health Services NHS Trust (LCHS) was extremely close and had resulted in continued development and enhancement of the Clinical Assessment Service to improve access to the Urgent Care system; and

·         Police and Fire colleagues regularly shared learning and training through the national JESIP Programme and through collaborative working in Lincolnshire Resilience Forums.  Financial efficiency and quality improvement through the shared premises programme "blue light campus".

The operational restructure of EMAS was also reported which was intended to provide an enhanced clinical leadership response to critically ill patients whilst providing greater face-to-face management for frontline clinicians.

The response times were further explained to the Committee for ease of consideration of the report:-

1.   The clock was initially started when the call connected to the switchboard prior to being answered;

2.    Initial discussion with the call handler would ascertain if the patient was conscious or breathing;

3.    If yes, an extra minute was allocated to find out what the problem may be, therefore the start time is either 0 seconds or 60 seconds;

4.    The clock would stop (for RED1 or RED2 calls) when a responder with a defibrillator reached the patient; and the clock would stop for a RED19 call was when an ambulance arrived capable of conveying the patient to hospital.

Members were invited to ask questions, during which the following points were noted:-

·       It was acknowledged that the use of emergency ambulances to take patients home, following hospital treatment did occur in some cases, however, it was not to be promoted.  A third party provider was responsible for patient transport in Lincolnshire.  An exception to this was where a person wished to return home to die then the ambulance would undertake that journey with the patient to ensure clinical safety;

·       Ten new ambulances had been allocated to the Lincolnshire Division, the older vehicles had also been retained.  In addition, all maintenance work was done within the divisions rather than one central place in the East Midlands which had further reduced 'vehicle off the road' times;

·       When ambulances were engaged, an email was sent by EMAS to GPs, coroners and any other required professionals.  However, there was no way to guarantee that these emails had been read.  The method of communication was that emails were sent to one central point and redistributed to health professionals.  It was then noted that the email had been delivered whereas there was no confirmation that the previous method of faxing information had been delivered;

·       The standard mobile network across the county was currently used with the existing Toughbooks gathering information as and when signal was available.  Radios for the emergency services were to be replaced on a rolling programme from 2019 and it was expected that the Toughbooks would link to the data provided by the radios;

·       It was suggested that the triage car, based in Lincoln, would not travel to the south of the county if there was an issue with, for example, a drugs overdose.  In some of these cases, police officers had transported these patients to the nearest appropriate unit, generally in Lincoln.  It was acknowledged that there had been reports of incidents of this type which, when investigated fully, were found not to be as initially reported.  The triage car worked only between the hours of 4.00pm and 2.00am and some of these incidents had occurred out of those hours.  It was agreed that the police should not be transporting patients, however it was stressed that there was only so much resource available and that, on occasion, ambulance crews were called, inappropriately, to incidents of assaults;

·       Appendix C to the report showed the number of vehicles at hospital over quarter 3 but the figures had a number of parameters attached to them and further clarity was requested.  The Committee asked that consideration be given to the presentation of these figures in future reports to ensure that the figures were clear;

·       After patients had been passed to Accident and Emergency staff at hospitals, crews were allowed 15 minutes to restock, tidy and clean the ambulance and take a comfort break ready for the next call.  Crews in the Lincolnshire Division took less than 15 minutes overall.  Staff were able to observe patients undergoing resuscitation, for ongoing development, should authorisation be given which meant crews may be at an Accident and Emergency site for over an hour.  Staff were encouraged to stay and watch procedures as this contributed to 'on-the-job' training;

·       Despite the performance figures and report presented, one Member of the Committee expressed thanks to EMAS and highly commended the crews, having had personal experience over recent weeks.  The crews and hospital staff had worked non-stop to provide the most appropriate care and the Committee were asked to recognise the endeavours of the staff, in this challenging time;

·       Concern was noted that the performance levels had been reduced as Commissioners were aware that national standards could, and would, not be met.  By setting local performance requirements as part of the contract, EMAS had been given realistic targets;

At 11.20am, Councillor Miss E L Ransome left the meeting.

·       The time difference between a LIVES first responder arriving at a scene and a professional, including an explanation of the impact on the system and reporting, was requested;

·       Full training was provided to all crews on the Toughbooks, however those who identified the need for further training were given extra support.  Staff within the hospitals would also be available for further support and by the end of 2017 it was expected that all crews would be using this equipment, which was mandatory;

·       The Hospital Ambulance Liaison Officer (HALO) was not a funded role within the hospital but an ambulance manager who had been given that title.  This was an attempt to turn crews around faster and this officer would liaise with the nurses in charge.  The Committee was asked to note that this role was in support of the hospital but that the person in this role was an ambulance manager who should be otherwise supporting ambulance staff;

·       Although a regional service, the 'drift' from Lincolnshire into neighbouring counties had been a major concern over the last year.  It was reported that this had reversed in Quarter 3 which meant Lincolnshire had been in a much better position than in previous quarters.

At 11.37am, Councillor Mrs P F Watson left the meeting.

The Chairman thanked EMAS representatives for their attendance and presentation and requested that an update be added to the Committee's work programme for the meeting scheduled for Wednesday 20 September 2017.

RESOLVED

1.    That the report and content be noted; and

2.    That a further update be added to the Committee's work programme for 20 September 2017.

At 11.40am, Councillor J Kirk left the meeting.