WELSH AMBULANCE SERVICES NHS TRUST EMERGENCY MEDICAL SERVICES IN WALES

32 Pages·2008·0.13 MB·English

WELSH AMBULANCE SERVICES NHS TRUST

EMERGENCY MEDICAL SERVICES IN WALES

An Assurance Review for the Minister for Health and Social
Services

Stuart Fletcher
David Galligan
Morton Warner

Review Group May 2008
CONTENTS

Foreword 1

Key Messages 2
Recommendations 3

Review

1 Remit and Terms of Reference 7
2 Auditor General’s Recommendations and Other Context 8
3 Consultation 9
4 Stakeholder Views 10
5 Further Background 12
6 Major Issues 13
6.1 Corporate Governance 13
6.2 Category A Response 14
6.3 Urgent Admissions 15
6.4 Turnaround Times 16
6.5 Thrombolysis – Call to Needle Times 18
6.6 NHS Direct Wales 19
6.7 Delivering Emergency Care Services (DECS) 19
6.8 Information 19
6.9 Fleet 20
6.10 Procurement 20
6.11 Financial Management 20
7 Challenges Remain 20
7.1 Significant Challenges Remain 21
7.2 Regional Variations in Standards 21
7.3 Staff Survey Results and Issues of Morale 21
7.4 Education and Training 22
7.5 Deployment of Rapid Response Vehicles 23
7.6 Excessive Turnaround Times 23
7.7 Matching Supply and Demand 24
7.8 Estates Strategy 24
7.9 Financial Risks 24
7.10 Locality Targets 25
7.11 Implications of Reconfiguration 25
8 The Modernisation Plan 25
9 Infection Control and Cleanliness of Vehicles 27
Appendices

Appendix 1 Auditor General for Wales’ Update
Appendix 2 Auditor General’s Review of Progress against each
of his original recommendations
Appendix 3 Professor Warner’s Review of the Trust’s
Modernisation Plan
Appendix 4 Dr Looker’s Report on Infection Control
FOREWORD

In December, 2006, the Auditor General for Wales published a seminal report on
the Welsh Ambulance Service. It identified problems of long standing but
expressed clear grounds for optimism that these could be resolved over time,
given the underlying strengths within the organisation and the steps already
taken by a new management team to implement its modernisation plan. A little
over one year later, the overall conclusion of the Review Group is that
emergency ambulance service provision in Wales is now in a stronger position
than it was.

We understand that the Trust has always made it clear that substantial
transformation and change can only be accomplished over a longer timescale. A
five year period was identified for the achievement of the major aspects of the
Trust’s modernisation plan. The Review Group agrees with this position. Some
difficult problems remain and these are fully examined in the review, but this is
perhaps only to be expected at this stage in the organisation’s evolution. It is now
timely and appropriate to report progress and assess how far plans are on track,
but the Review Group believes that the Trust’s work needs to be viewed in this
longer term perspective.

Compliance with Assembly response time targets is inevitably a first
consideration, not for its own sake but because of the very real difference it
makes to the health and well being of patients. It is right that we highlight the
issue of response times: performance has improved over the previous year in
spite of the adverse challenges that the Trust faced through another difficult
winter period. The Review Group is pleased to note that WAST performance has
recovered, following those winter pressures on hospitals and ambulances alike,
though wide variations remain and must be addressed. A detailed analysis of
performance is provided in the review.

It is unsurprising that a period of significant organisational change has added
considerably to pressures on staff at all levels in the Trust. The impact on staff
has been made very clear to us in several meetings held with their
representatives during the course of the review. The Review Group recognises
that the Trust Board is conscious of this but we would emphasise that addressing
issues of staff attitude, morale and development must be a main priority, with
greater staff engagement in the change process. This issue is covered later in
the report and also extensively in Appendix 1.

We cannot stress enough how important it is that the Trust works closely with its
health and social care partners in achieving the full range of its objectives. The
publication of the Assembly Government’s “Delivering Emergency Care Services”
(DECS) strategy is a major step forward and we think that it is important for the
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Trust to continue to develop its strategic partnerships in this context. The
constructive working arrangements already forged to address key problem areas,
such as ambulance turnaround times, have proved to be beneficial and a
foundation for further work in this context.

In carrying out the review, we are grateful to Professor Morton Warner for his
analysis of the Trust’s modernisation plan and implementation programme and to
Dr Nick Looker for his examination of infection control and cleanliness of
ambulance vehicles. Both these contributions will be of considerable assistance
to the Trust as it moves forward.

In scoping the work of the review, it soon became clear that the considerable
experience and expertise gained by the Auditor General for Wales and his team
in compiling the original report would be an invaluable asset. This expertise was
particularly relevant given the Auditor General’s undertaking, to the Audit
Committee of the National Assembly, to report back on progress made since the
Committee considered the Auditor General’s report and made its own
recommendations. With the agreement of the Auditor General and the support of
the team who carried out the original work, the Review Group has made full use
of this contribution, which is reflected in the detailed analysis of the Trust’s
current position provided in Appendices 1 and 2 to the Review.

What then, in our judgement, are the key messages to be taken from our
examination of this work in progress to develop and improve the Welsh
Ambulance Service as a vital component in the provision of unscheduled care to
the people of Wales? We conclude that:-

• progress has been made against all twenty four recommendations in
the Auditor General’s report in respect of the Trust’s emergency
medical services;
• overall performance has improved in the last year - by 6.2% in
respect of the A8 first response and by 9.5% for the 14/18/21 minute
standard for an ambulance response;
• GP urgent performance has been much improved – from 63% in
January, 2007 to 81% in February, 2008;
• although performance has improved it remains unsatisfactory in a
number of, mainly rural, areas and many recommendations are
aimed at addressing this in both emergency and unscheduled care;
• the Trust must work harder to match demand and supply more
closely;
• the number and speed of changes and the way they have been
implemented has had a serious adverse effect on staff morale;
• management arrangements, capacity and style will need review,
particularly to address areas of poor people management and
perceptions of a bullying culture;
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• the slow introduction of clinical team leaders has had a detrimental
effect on local management arrangements;
• training and development remains an area of concern, in particular in
relation to appraisal and skill development;
• it is clear that the expansion of the Community First Responder
Scheme has led to significant difficulties in terms of contact, role
clarity and support by the Trust;
• the capital investment, especially in new vehicles, has been widely
welcomed;
• corporate governance has improved significantly in the Trust;
• clinical governance is improving but is still in need of further
development;
• joint working and communication with other emergency services
needs improving;
• the finances of the Trust are stable, but it faces a number of
challenges which will need to be addressed;
• Professor Warner has made a number of recommendations aimed at
improving the effectiveness of “Time to make a Difference” which,
overall, he regards as robust.;
• Dr Nick Looker, whilst generally commenting favourably on infection
control, has made a number of detailed recommendations to
underpin the Trust’s future approach to this important area.

We believe this review demonstrates that the Trust has the ability to resolve its
remaining problems in the suggested five year timescale but that it is essential
that it takes steps to ensure that staff are fully engaged in this process.

We have made sixteen additional recommendations which the Trust needs to
address in continuing to move forward. These are as follows:-.

Performance

Recommendation 1

The Trust should build on its good work with acute trusts and LHBs to
develop robust plans to address excessive handover and turnaround times
where there are particular problems and to ensure compliance with the new
WAG fifteen minute standard.

Recommendation 2

In monitoring performance, the Trust and its commissioners should also
focus on

• the time taken to back up the initial response;
• clinical indicators such as call to needle time;
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• improving benchmarking data to inform decision making;
• patient transportation rates;
• improved specificity of call categorisation.

Strategy

Recommendation 3

The Trust should strengthen its strategic planning capacity to develop a
clearer vision of the future delivery of ambulance services. As part of this it
should also develop a clear plan to improve relative performance in South
East Wales Region with a clear timetable for the realisation of its goals.

Recommendation 4

The Trust should review its communications strategy to increase
awareness of the role, purpose and impact of the modernisation
programme and its implementing department so as to increase the sense
of local ownership.

Recommendation 5

The Trust should work with NHS partners to:-

• develop a clearer understanding of the volume and nature of demand
for unscheduled care services;
• redesign service provision to meet that demand through alternative
service models;
• reduce pressure on accident and emergency departments through
the development of new care pathways which minimise the number
of patients taken there inappropriately;
• promote relevant training and education programmes to better equip
staff to provide an enhanced range of clinical services that would
allow them to treat and refer an increasing number of patients
without transporting them to hospital;

Governance

Recommendation 6

The Trust should maintain its progress towards integrating clinical and
corporate governance, embed and disseminate key policies and develop
clinical governance structures to support new models of service consistent
with the vision set out in the Assembly Government’s strategy for
unscheduled care, Delivering Emergency Care Services (DECS);
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Leadership

Recommendation 7

The Trust should further support the development of its executive team
and non executive team to better equip them to meet the heavy demands
upon them.

People and culture

Recommendation 8

The Trust should develop local champions of change to build management
capacity at that level. Locality Ambulance Officers, Clinical Team Leaders
and other key front line staff will be crucial elements in this process.

Recommendation 9

The Trust must support staff through early recruitment of clinical team
leaders, with a clear role, time allocation and management development
programme for those appointed.

Recommendation 10

Arrangements for performance appraisal and the identification of
development needs must be put in place for all staff. The Trust should
make this a priority and set a firm timetable for its achievement;

Recommendation 11

The Trust should develop a clear strategy to address issues of morale. It
should set clear objectives for its executives, managers and supervisors to
contribute to improved morale, as well as improving understanding of the
modernisation programme. The ideas emerging from staff focus groups
will inform the development of the programme.

Process

Recommendation 12

The Trust should build on good progress achieved in analysing demand,
changing rosters and developing information systems, by developing
detailed local analysis, reviewing allocation of resources between regions,
refining demand analysis and developing new service models - particularly
in meeting the unique needs of sparsely populated areas and learning
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lessons from adverse incidents. The engagement and participation of staff
of staff is crucial to this process.

Recommendation 13

The Trust should build on its early work concerning clinically driven, triage
based call handling and despatch systems, taking advantage of the
experience being gained in the commissioning of the new south east
control at Vantage Point House.

Capacity, systems and infrastructure

Recommendation 14

The Trust should agree a clear capital development framework with WAG,
supported by a rigorous benefits realisation framework linking capital
investment with the delivery of performance improvement.

Recommendation 15

The Trust should develop a clear and detailed estates strategy, with a
coherent approach to rationalisation, compliance with statutory duties,
make ready facilities and social deployment points.

Recommendation 16

The Trust should implement the advice received regarding infection control
and ensure that it benefits from playing a full part in the wider NHS Wales
arrangements.

Stuart Fletcher Chair of the Review Group and Chair of the Welsh Ambulance
Services NHS Trust

David Galligan Head of Health, Wales Region, UNISON
Morton Warner Professor of Health Strategy and Policy, Welsh Centre for
Health and Social Care, University of Glamorgan

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WORK IN PROGRESS – A REVIEW OF THE WELSH AMBULANCE SERVICE

1 REMIT AND TERMS OF REFERENCE

1.1 The Minister for Health and Social Services, Edwina Hart, asked Stuart
Fletcher as Chair of the Welsh Ambulance Services NHS Trust (WAST), to lead
a review of emergency ambulance services in Wales. She asked for a report by
30th April, 2008, on:-

• the progress the Welsh Ambulance Services NHS Trust has made against
the recommendations of the Auditor General’s Report on Ambulance
Services in Wales published in December, 2006;
• the robustness of the Trust’s five year modernisation plan “Time to Make a
Difference” (TTMD) and its ability to deliver the further improvements
required of the service;
• progress against the actions identified in the plan;
• the effectiveness of infection control and cleanliness in ambulance
vehicles.

1.2 This review is restricted to emergency ambulance services. The Minister has
sought a separate report on the Welsh Air Ambulance Service. Non emergency
patient transport will also be the subject of a separate, independent report which
will examine the role of all public organisations who act as providers of this
service in Wales, WAST being an important component.

1.3 The other members of the Review Group were David Galligan of UNISON
and Professor Morton Warner of the Welsh Institute for Health and Social Care at
the University of Glamorgan, who have provided independent advice. Professor
Warner has provided specific advice in relation to the effectiveness of the Trust’s
ongoing modernisation plan (Appendix 3). Mr Galligan has taken a particular
interest in staffing matters.

1.4 In addition, an expert Reference Group of key stakeholders has also been
fully involved in the preparation of the report and has made an important
contribution. This has comprised Stuart Davies (Health Commission Wales),
Derek Griffin and Elwyn Price-Morris (Welsh Assembly Government), Gill Lewis
and Rob Powell (Wales Audit Office), Councillor John Maclennan (Board of
Community Health Councils) and Alan Murray (Welsh Ambulance Services
Trust).

1.5 The work of the Review/Reference Groups, as well as benefiting from Wales
Audit Office (WAO) membership, has also been assisted by significant specialist
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