How is our ambulance service evolving for the future?

Changing response models and better integration of services mean that the ambulance role can increasingly have an impact in improving patient experiences and outcomes, by providing more diagnosis and treatment in the community setting, reducing the number of interactions patients need to make with services for each episode of care, ensuring care is provided closer to home and avoiding hospital attendance and admission when it is not needed. All of this is at the heart of the NHS Long Term Plan (LTP), launched in January 2019.

Over the past two years the NHS has introduced new ambulance standards to ensure the best, most appropriate response is provided for each patient first time.

NHS England has stated that its aim is that by 2021 all ambulance services will:

• Meet all targets and deliver all patient outcomes;
• Be efficient and effective;
• Have a satisfied, happy and productive workforce;
• Be integrated into the wider Urgent & Emergency Care System;
• Be digitally fit for the future.

Ambulance services are changing to work in different ways. This means that patients are treated by skilled paramedics in their own home, given advice over the telephone or taken to a more appropriate setting outside hospital.

Challenges facing Ambulance Trusts across the UK

The NHS continues to face substantial and sustained rises in the demand for urgent and emergency care. Whilst each region and country within the UK faces its own unique challenges there are common challenges that every ambulance service is facing:

• The population is growing and aging, meaning more patients and greater complexity
• There is an increasing prevalence of acute and complex long-term conditions
• The need for care of critically ill patients is growing at a higher rate
• New technologies are changing how patients access the care system
• Recruitment difficulties within frontline and support functions

In September 2018 Lord Carter produced a comprehensive report into ambulance productivity in England, with nine recommendations to improve patient care, efficiency and support for frontline staff who have responded to a significant rise in demand for ambulance services in recent years. The full report can be found here, but some of the recommendations are already being implemented and discussed below.

So how are ambulance services across the UK adapting and changing to face current and future challenges?

Ambulance Response Programme

The aim of the Ambulance Response Programme (ARP) has been to explore strategies that can support operational efficiency and performance and improve the delivery of high quality care for patients. Over an 18 month period from October 2015 to April 2017 two major changes were made to ambulance service operations – the introduction of additional time to triage 999 calls to enable better dispatch of an appropriate response (Dispatch on Disposition) and a revision of call categories to support provision of responses that are a better fit between urgency, clinical need and appropriate response. After careful piloting and evaluation the decision was made to implement ARP across all ambulance services in England in July 2017 and this was achieved by November 2017.

Following successful implementation of the Ambulance Response Programme, it has become clear that trusts need to understand more clearly how and why people use Ambulance Services to improve the way in which patient care is delivered.

The Ambulance Data Set (ADS) is intended to do just that. Developed by clinicians, this new data set will provide an improved, consistent level of detail about how ambulance services respond to and treat the thousands of calls that are received by the 999 service every day, which have never been collated consistently before.

The new data set will be particularly important in understanding how and why people access urgent and emergency care, so trusts can improve their planning to reduce pressure in the system.  The end result will be to improve patient outcomes, safety and experience.

Transforming the ambulance service across the four nations

The following podcast from the NHS Confederation and the Association of Ambulance Chief Executives explores how integration is playing out across the four home nations, with a particular focus on the role ambulance services are playing.

The 17-minute discussion, hosted by Heather Moorhead, Director of the Northern Ireland Confederation for Health and Social Care, identifies how all four countries are different but share the same goals and how ambulance services, which often transcend local health economy footprints, are able to give a different perspective to integration.

In the podcast we hear from:

• Jason Killens, Chief Executive of the Welsh Ambulance Service NHS Trust
• Michael Bloomfield, Chief Executive of the Northern Ireland Ambulance Service
• Rod Barnes, Chief Executive of Yorkshire Ambulance Service NHS Trust
• Claire Pearce, Director of Care Quality and Strategic Development at the Scottish Ambulance Service

Project A

Led by Helen Bevan, Chief Transformation Officer of NHS Horizons, and delivered by NHS Horizons and the Association of Ambulance Chief Executives, Project A allows a cross section of frontline staff to share their experiences, gather a reflection of insights into the way urgent care works on a daily basis, and explore ideas from the frontline that lead to improvements across ambulance services.

The overarching aims of Project A are to:

• identify and mobilise frontline ambulance staff (both frontline clinical teams and in control centres) and patients to contribute to improvement
• identify issues the crews want to work on that will have a positive impact
• develop, test and implement solutions, using and building on existing programmes and creating new ideas, that add up to significant improvement
• Project A starts with the question: “How could we speed up and broaden improvement if we worked with frontline teams and patients to identify and implement new ways of working that would add up to large scale change?”

From an initial 608 ideas from frontline staff, six specific activities emerged for further work and progression:

1. Action on falls: The aim is to develop and implement a falls response framework that will be relevant to every ambulance service and that will lead to better, more appropriate services for people who fall, less conveyance and/or help stop people from falling in the first place or falling again.

2. Action on mental health and emotional distress: To create an actionable “knowledge bank” for use by frontline ambulance staff and share and test approaches to supporting people in mental health crisis and emotional distress.

3. Action on partnership: people, families and the wider community: To co-produce a campaign that focusses on how to access and use services. It will be a two-way partnership, created in the spirit of community engagement, co-creation and activism, using multiple communication channels including social media.

4. Action on staff wellbeing: Develop a virtual collaborative that looks to support ongoing work within the Human Resource Directors’ Group (HRDs) and Strategic Partnership Forum (trust and union representatives) with a focus on implementing clinical supervision across all ambulance services.

5. A directory of ideas for improvement: Share the 70 ideas with the most potential for implementation from the #ProjectA ideas platform and create a series of challenges to help make trusts introduce them.

6. Virtual collaboration: Build the capability of the ambulance workforce to collaborate virtually; reducing time away from work and abstraction; increasing opportunities for sharing, learning and speeding up change.

Mental Health

The ambulance service and its workforce face specific challenges and unique circumstances within the health and care system.

With the support of its member trusts, all UK NHS ambulance services, the Association of Ambulance Chief Executives (AACE) has produced the following film capturing the mental health experiences of some of ambulance staff.

NHS Employers has created a set of resources called Ambulance Workforce to support all employees in the ambulance service. Ambulance workforce aims to develop organisational cultures that promote higher levels of morale, motivation, staff satisfaction, wellbeing and engagement, to improve the working lives of all staff in the ambulance service and, ultimately, help to deliver the best possible patient care.

Ambulance Workforce has been developed in partnership with employers, trade unions and NHS Employers and supported by the Association of Ambulance Chief Executives and the National Ambulance Strategic Partnership Forum.

Technology

In his report, Lord Carter showed how utilising new technology across the ambulance service could improve the efficiency and effectiveness of the service for patients aligned with the roll-out of the Emergency Services Network (ESN).

The initial focus for the ambulance service, led by the Ambulance Radio Programme, has been to ensure that ESN is implemented effectively with no loss of service. However, ESN provides the capability to radically transform the way patient care is delivered in the long term.

This post is only a snapshot of the great work that the ambulance services across the UK are doing to continually improve their services to the public. We salute each and every one of you, working so hard to save lives. Thank you!