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 Key Messages Recommendations Review 1 Remit and Terms of Reference 2 Auditor General’s Recommendations and Other Context 3 Consultation 4 Stakeholder Views 5 Further Background 6 Major Issues 6.1 Corporate Governance 6.2 Category A Response 6.3 Urgent Admissions 6.4 Turnaround Times 6.5 Thrombolysis – Call to Needle Times 6.6 NHS Direct Wales 6.7 Delivering Emergency Care Services (DECS) 6.8 Information 6.9 Fleet 6.10 Procurement 6.11 Financial Management 7 Challenges Remain 7.1 Significant Challenges Remain 7.2 Regional Variations in Standards 7.3 Staff Survey Results and Issues of Morale 7.4 Education and Training 7.5 Deployment of Rapid Response Vehicles 7.6 Excessive Turnaround Times 7.7 Matching Supply and Demand 7.8 Estates Strategy 7.9 Financial Risks 7.10 Locality Targets 7.11 Implications of Reconfiguration 8 The Modernisation Plan 9 Infection Control and Cleanliness of Vehicles
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2 3
7 8 9
10 12 13 13 14 15 16 18 19 19 19 20 20 20 20 21 21 21 22 23 23 24 24 24 25 25 25 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
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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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input and analysis from the WAO team. We were particularly keen to work in partnership with the WAO, because of the strength of their original report and the independent verification and authentication that their involvement would bring. For this reason, the Review Group’s analysis of the Trust’s response to the original recommendations in the December 2006 report is substantially built on the WAO’s updated and detailed examination of progress set out in Appendix 1 to this Review. An evaluation of the Trust’s response to each of the twenty four relevant recommendations from the original Auditor General’s report is summarised in Appendix 2. We are most grateful to the Auditor General for Wales for this support. The Auditor General already planned to report back to the National Assembly’s Audit Committee. The Review Group and the Auditor General anticipate that the work carried out for this review will contribute substantially to that end. 1.6 Dr Nick Looker, Consultant Microbiologist with the National Public Health Service based at Conwy and Denbighshire NHS Trust has provided expert evidence and advice on infection control and the cleanliness of ambulances (Appendix 4). We are very grateful to him for his ready agreement to lead this part of the review, the conclusions of which will be of great value to the Trust in improving its performance in this vital area. 2 AUDITOR GENERAL’S RECOMMENDATIONS AND OTHER CONTEXT 2.1 In response to a vote in the National Assembly to hold an inquiry into ambulance services in Wales, the Auditor General for Wales published a report in December 2006.That document pointed to long standing and deep seated problems in the service. He showed that a number of key strengths within the Trust had been let down by problems of strategy, leadership, governance, process, infrastructure, and systems, people and culture. 2.2 The report concluded that patient care had been compromised by the Trust’s consistent failure to provide sufficiently responsive emergency ambulance services. However, it said that the Trust’s problems could be resolved over time provided key challenges were successfully met. There were grounds for optimism because of the modernisation plan “Time to Make a Difference” and the fact that other ambulance services had turned themselves round. 2.3 The challenges to the Trust, both external and internal, identified in the Auditor General’s report were encapsulated in a set of twenty eight recommendations for action, many of them with several sub recommendations. Twenty four of the recommendations related to the emergency ambulance service and these were grouped under the following seven headings:-
• Performance • Strategy
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• Governance • Leadership • People and Culture • Process • Capacity, Systems and Infrastructure
2.4 The Auditor General’s report acknowledged that the Trust’s modernisation plan, then in draft form, set out a direction to address the weaknesses identified. The plan has two main areas of focus:-
• building confidence in the service’s ability to deliver as a traditional ambulance service in the short term;
• leading a more fundamental process of change over a longer period – in effect delivering patient care differently in keeping with WAG’s developing strategy for delivering emergency care (DECS).
2.5 Apart from the Auditor General’s report, the decision to locate the services of NHS Direct Wales within WAST, with effect from 1st April, 2007, has also provided an impetus to the Trust’s wider development as a major provider of emergency and unscheduled care. 2.6 Another source of impetus has been the development of the Trust’s own modernisation plan. We acknowledge that the Trust Board has always made it clear that its modernisation plan can only be fully realised in the medium to long term, with an initial five year timescale recognised as a sensible period over which the success of its plan should be judged. Notwithstanding this, the Board anticipated real progress towards, and achievement of, some of the plan’s goals over a much shorter period. 2.7 We have been able in this review to analyse in detail the progress made by the Trust in meeting the recommendations of the Auditor General’s report (Appendix 2). In some cases these have already been met in full; in others it is still work in progress against the background of complex technological change, stringent financial discipline and a change management programme that is a test for Trust management and staff at all levels of the organisation. 3 CONSULTATION 3.1 In preparing this review we have consulted with a wide range of groups with a close interest in the provision of first class emergency ambulance services. These have included Assembly Members, NHS partners - Trusts, Local Health Boards and Local Medical Committees, the Community Health Councils, Unitary Authorities and the other providers of emergency services in Wales. We have also been particularly keen to take the views of staff and community first responder groups. In addition, the general public has been given the opportunity to comment through notices in the local press.
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3.2 We have been informed by a series of meetings with a number of the above interests and have also met the Trust’s auditors and Health Inspectorate Wales. We have been particularly keen to meet staff side representatives and have found these meetings of great value. 3.3 With the support of the WAO, five focus groups were arranged to seek the views of staff. Software was used which enables participants to submit views anonymously, to see the views of other participants and to assign priority to them. Groups were arranged, selected randomly, in each of the three regions. In addition, there were separate sessions for staff side representatives and locality ambulance officers, whom we also met as a group. The views expressed, and ideas put forward for improvement, should prove to be valuable additional tools for the Trust in planning the way forward. 4 STAKEHOLDER VIEWS 4.1 The Review Group consulted with a wide range of stakeholders, as detailed in the previous paragraph. Broadly speaking there was support for the Trust, its direction of travel and recognition of the skill and dedication of front line staff. There were also a number of expressions of concern, chiefly about local variation in performance, rurality and cross border issues, the need to learn from adverse incidents, lack of management capacity to effect changes, adequacy of staff cover, misuse of the 999 service, handover arrangements in A&E and adequacy of Rapid Response Vehicle (RRV) backup. 4.2 The Review Group met with staff representatives in all three regions and very valuable feedback was received. The report refers elsewhere to understandable issues of low staff morale at a time of rapid and significant change. This was reflected in the meetings with staff side who expressed a range of concerns. These included:-
• an over emphasis on response times; • pressure to make savings at the expense of service; • pace of change; • management style and cultural issues, including bullying, leading to
feelings that staff are not valued; • rota design and matching this to demand analysis; • consequent pressures on control; • staffing levels; • conditions of service including travelling time and meal break issues; • meal break issues; • deployment arrangements • lack of management accountability; • the deployment of RRVs and ambulance back up;
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• clinical team leader structure; • lone worker policy and personal security issues; • out of area call outs; • higher percentage of Category A calls; • work/life balance and adverse effects on family life; • the relationship with the unscheduled care department; • call triaging; • lack of alternative care pathways; • managers not listening to staff; • regional inconsistencies; • absence management; • Agenda for Change bandings; • poor application of the Knowledge Skills Framework (KSF); • management training and education; • accountability of crews; • communication; • vehicle equipment range; • vehicle cleanliness; • development of resource centres and project management.
4.3 This is not an exhaustive list but serves to underpin the Review Group’s concern about management style, staff morale and the need to tackle this at its root. The most worrying aspect of this was a continuing lack of confidence amongst staff about the quality of people management, the translation of strategies into action and deep seated cultural problems. Staff complained that some local management did not listen to their views together with a strong perception of a bullying culture. 4.4 Staff side views were reinforced in the five staff focus groups conducted by the WAO, where similar concerns and criticisms were articulated. We regarded the results of these as an important contribution and note that they mirrored our findings and those of the WAO. We expect the Trust to carefully examine the outputs of these groups and to learn from and take advantage of the rich feedback provided. This included a wealth of positive suggestions for improvements in the quality of clinical care, the quality of clinical equipment, fleet and emergency care services generally. The potential solutions suggested by the Groups included:-
• more investment in human resource development and training; • investment in control to improve triaging and introduction of alternative
care pathways; • focus on patients rather than targets; • improved prioritisation of emergency calls; • a whole system approach to hospital turnaround and bed management; • greater emphasis on public education;
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• greater level of staff engagement in the modernisation plan; • further devolution to regional and local level; • more grass roots involvement by the Board; • improved managerial capacity and clearer opportunities for staff
progression; • development of a listening culture throughout the organisation; • measures to improve morale by tackling work environment and conditions
of service issues; • rewarding staff for their achievements and supporting them when things
go wrong.
As a Review Group we were impressed with the constructive views put forward by the Focus Groups. There is no doubt that the WAST staff care very deeply about their service and want to play a full part in the process of modernisation and improvement. The Trust must take full advantage of the opportunity that this provides. 4.5 We also had a response from the Joint Emergency Services Group (JESG), a voluntary grouping to promote emergency service collaboration in Wales. The Group has expressed its continuing support for the Trust’s modernisation plan but has concerns about joint working arrangements, both strategic and operational, which need to be addressed. The Review Group regards these as a key priority and was pleased to note that early discussions within JESG have already taken place. The construction of a common data base about adverse incidents and ways of enhancing co-operation on major incident planning are examples of joint work in progress. 4.6 The Review Group also received valuable feedback from representatives of community first responders who form an important part of the Trust’s plans. The enthusiasm and dedication of these volunteers is widely appreciated within the Trust. However, through this consultation and as part of the Trust’s own deliberations, a number of points have been raised which will require detailed consideration, particularly difficulties identified in terms of contact, role clarity and the overall support arrangements provided by the Trust. The Review Group stresses the need to address these matters as a priority and understands that further planned extension of first responder provision will be put on hold until they are resolved. 5 FURTHER BACKGROUND 5.1 In 2007/8 the Trust received £87 million as contract income for emergency medical services from its main commissioner, Health Commission Wales – this out of a total turnover of £136 million. Other income received by the Trust included funding for NHS Direct Wales and for the Patient Care Service. The Trust has remained on track to achieve its financial targets and will deliver over
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£12 million of recurrent savings through its current Service Change and Efficiency Plan (SCEP). 5.2 The modernisation plan includes specific priorities for development as a precursor to both improved patient care and performance. In headline terms these are:-
• partnership working with other NHS Wales organisations, health professionals and local authorities both in developing both alternative care pathways and dealing more effectively with patients once transferred to the acute sector;
• greater devolution to the Regions with emphasis on business continuity and resilience including the appointment of three regional directors and dedicated financial, estates, HR and communications support;
• a new control centre for the South East Region at Vantage Point House, Cwmbran, and upgraded facilities in Central/West and North Regions to ensure comparison with the best in the UK;
• improved information flows to ensure more effective deployment and use of resources;
• improved demand analysis and a closer match of shifts to activity; • increased and more effective use of community (alternative) first
responders; • taking full advantage of improvements in technology including the
Ambulance Radio Re-procurement Project (ARRP); • better triaging in control through a range of innovative measures to reduce
the number of patients transferred inappropriately to acute facilities; • building on the many advantages of full integration with NHS Direct Wales; • improved opportunities for education, training and management
development, particularly for middle management; • a Trust wide performance development framework.
6 MAJOR ISSUES 6.1 Corporate Governance. A particular concern of the Auditor General’s report was the Trust’s corporate governance arrangements. The need for a robust system of accountability is fundamental to the corporate health of the organisation. The Review Group noted that the Chairman has made this a personal priority. The Trust was independently reviewed by the Assembly’s Governance in Health (GIH) team in November, 2007. The Review Group was mindful that this team had given a very positive report on the governance of the Trust as recently as November 2007 and has largely relied on these findings. Further work to build on this strength, as recommended by the GIH team, is detailed in the appendices and the Review Group stresses the importance of addressing these issues, particularly those concerning management capacity, at both executive and non executive level.
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The Review Group was particularly encouraged by the Report’s conclusion that the Trust is working hard to establish strong, well developed governance arrangements, supported by clear definitions of roles and responsibilities. Additionally, strong and focused leadership is contributing to the establishment of a Board with a good skills mix and a maturing outlook, willing to take on the increasingly challenging agenda. The identification of a number of areas of good practice in the report was also a source of satisfaction, but we noted the expressed need to ensure that good practice at Board level is cascaded throughout the organisation and the continued need to ensure that good work with partners and stakeholders is maintained. It was noted that theTrust now has new leadership across virtually all its departments and has devolved increasing responsibility to the regions, with delegated budgets to regional and locality level. The Board is subject to a regular performance management regime involving both executive and non executive directors. Additionally, the Board is supported by a revised committee structure, updated standing orders conforming to accepted best practice and increased involvement of staff side representatives in line with WAG guidance. 6.2 Category A Response. The achievement of the eight minute Category A response time – a resuscitation response to a life threatening emergency - is universally regarded as a primary indicator of Trust performance. This first response is not necessarily an ambulance - it could be a rapid response vehicle or a community first responder. The Review Group noted the improvement in this standard for 2007/8, over 6 percentage points in comparison with the previous year as illustrated in the diagram below. This shows that the Trust was compliant with this standard which it had not met in any comparable month in 2006/7. It will, however, be noted that there was a dip in performance at the turn of the year which coincided with extended turnaround times at unprecedented levels and an unofficial overtime ban. The improvement in performance overall masks significant variations among localities and performance remains poor in a number of, mainly rural, areas. Further, overall response targets have increased for the new financial year and response standards will therefore need to improve to meet these new targets. Performance issues are covered in detail by the Wales Audit Office in Appendix 1.
Deleted: a
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Compliance with Category A8 standard
48%
53%
58%
63%
68%
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2006/07 2007/08 Standard Equally important are the 14/18/21 minute follow up standards for urban, rural and sparsely populated areas respectively, with a fully equipped ambulance expected to a level of 95% within the appropriate time frame for the area. Compliance with this standard is shown below. Whilst we noted that the standard has yet to be achieved, the Trust has made significant improvement in every month in 2007/8 -nearly ten percentage points over the year - except January, mainly for reasons explained in the paragraph 6.4.
Compliance with Category A14/18/21 standard
77%79%81%83%85%87%89%91%93%
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2006/07 2007/08 The graph shows that ambulances are reaching the scene more quickly than previously, on occasions as back up to RRVs, although there are documented instances of unacceptably long delays in ambulance back up, mainly in the south east as illustrated in the following table:-
Category A calls 30 minutes or under 30 to 50 minutes Over 50 minutes
WAST 121,214 (95.7%) 2,921 (3.4%) 791 (0.8%) North 27,498 (99.2%) 175 (0.6%) 23 (0.001%) Central and West 39,180 (96.1%) 816 (3.3%) 110 (0.6%) South East 54,536 (93.8%) 1,930 (3.3%) 658 (1.3%) All incidents 30m or under 30 to 50m Over 50m WAST 273,993 (94.7%) 10,678 (3.7%) 4,680 (1.4%) North 70,187 (98.9%) 709 (1.0%) 73 (0.1%) Central and West 89,913 (97.0%) 2,435 (2.6%) 431 (0.4%) South East 113,893 (90.7%) 7,534 (6.0%) 4,176 (3.0%)
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Source: WAO analysis of Trust data. 6.3 Urgent Admissions Despite some patchiness in performance, the trend analysis for urgent patients, booked for admission at a time specified, usually by a general practitioner, is positive. There was significant improvement in September 2007, when the Trust introduced its first dedicated high dependency crews and changed its processes for dealing with urgent requests in control centres. These should provide a platform for further improvement in this important standard which requires the Trust to deliver the patient to hospital no more than 15 minutes later than the time specified in 95% of cases.
Compliance with Urgent standard
56%
61%
66%
71%
76%
81%
86%
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2006/07 2007/08 6.4 Turnaround Times. We were informed that the problem of turnaround times is not unique to Wales with seven of England’s eleven ambulance trusts reporting difficulties this past winter. Despite a marked increase in turnaround times compared with 2006/7, we concluded that the Trust generally coped better this time round and it had no need to declare a major incident, as had happened the previous year. The position is illustrated in the graph below which shows turnaround times in excess of 50 minutes.
Turnarounds >50 minutes
8001000120014001600180020002200
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec2006 2007
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The Review Group highlights this as a fundamental issue which can only be addressed by the Trust in partnership with the wider NHS family. We were informed that the Trust has been able to form constructive partnerships in the most affected communities and joint initiatives have included:-
• implementation of clinical desk pilots at Mamhilad and Carmarthen control centres, staffed by senior and experienced NHS Direct nurses, to triage suitable patients to care pathways other than ambulance and A&E – to be extended to North Wales in 2008/9;
• availability of trolleys and stores for emergency crews at acute hospital sites with access to spares to enable them to re-equip;
• weekend duty managers and trigger paging of further managers early in the escalation process;
• improved liaison with local bed managers; • development of joint community action plans in Gwent and Cardiff & Vale,
linking with locality acute response and mental health crisis teams, with a similar initiative planned for Swansea;
• introduction of a rapid assessment process at Royal Gwent; • diversion arrangements with Nevill Hall; • extended use of the Medical Assessment Unit at University Hospital,
Wales with similar arrangements planned for Swansea; • development of a new care pathway with Gwent Out of Hours for patients
who need primary care rather than accident and emergency care; • increased use of minor injury units where available; • introduction of ambulance arrival screens at UHW; • development of protocols to facilitate direct admissions to coronary care
units where appropriate; • exploration of using a bed bureau style of urgent admission management.
We noted a high correlation between extended turnaround times and diminishing compliance with standards. An additional factor in December, 2007 was an unofficial overtime ban in South East Region which also affected the position in January. The chart below shows the effect of these two factors on equity in the period from February 2007 to February 2008.
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Category A eight minute compliance by LHB
0 5 10 15 20
Feb-07Mar-07Apr-07
May-07Jun-07Jul-07
Aug-07Sep-07Oct-07Nov-07Dec-07Jan-08Feb-08
>60% 50%-60% <50% From a low point of only four LHB areas in February, 2007, the Trust improved its compliance so that in only one month between May and September 2007 were fewer than fifteen LHBs fully compliant with the eight minute standard. As extended turnaround times rose and the effects of the overtime ban were felt, this fell to seven LHBs compliant in January, with five below 50%. During this period over half of hospital transfers – 56% of all Category A patient journeys –involved a turnaround time of longer than twenty minutes. WAO analysis has shown that the time lost through hospital handover times rose by 13% between 2006/7 and 2007/8 – a level sufficient to significantly reduce performance. The impact was particularly felt in the south east. Against this background, the Trust regards the partnership measures outlined above as a positive response to this problem of turnaround times. Clearly the joint working arrangements described are in the early stages of development but, together with the introduction by WAG of the fifteen minute turnaround standard from 1st April, 2008, we believe they will help to bring positive rewards to all partners in an environment that emphasises the needs and safety of the patient. It is anticipated that these successful pilot arrangements can be applied in other parts of Wales where, though problems have been less acute, there is still a need for concerted partnership action. The Trust is committed to a strategic approach and it is also involved in several health community projects. In Powys, for instance, an unscheduled care partnership board has been set up, addressing issues including minor injuries services and admission avoidance packages for older people. If successful, this will provide a model for other sparsely populated areas. 6.5 Thrombolysis of Patients - Call to Needle Time We also noted that the Trust has seen a continuing achievement of the Call to Needle Time (CTNT) 60 minute target in 2007/8. The target for the NHS in Wales specifies that 70% of patients should achieve thrombolysis within this timescale and the WAST performance contributes to this overall figure. For the second year in succession, WAST has far exceeded this level, even in the context of an increasing number of patients treated. In 2007/8, 91% of patients received
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treatment within 60 minutes – the figure was 90% in 2006/7. The graph below shows the monthly percentage of patients meeting the target during 2007/8.
We were informed that this success can be attributed to training and audit. A detailed report is provided to key stakeholders on a monthly basis and any cases falling outside the target are carefully reviewed, with feedback provided to the paramedics concerned and further training identified and provided if required. Collaborative audits, co-ordinated by the cardiac networks, are also regularly undertaken to identify any delays and review operational procedures to improve future outcome, particularly on a locality basis. This has led to a steady overall improvement. Dr Phil Thomas, Lead Cardiac Clinician for the Cardiac Networks, is working closely with WAST in this important area. He notes that achieving the CTNT target depends on rapid assessment by the paramedic at the scene and early administration of the thrombolytic drug, if the appropriate criteria are to be met. 6.6 NHS Direct Wales. One of the biggest changes within the Trust since the publication of the Auditor General’s report has been the joining with NHS Direct Wales in April, 2007. In addition to the nurse triage in control pilot, the Vantage Point House development in Cwmbran will bring together, this summer, the regional ambulance control centre, NHS Direct and Gwent Out of Hours service. The Review Group considers that this could provide a platform for a single point of access to the emergency and unscheduled care system in that part of Wales and will enable the Trust to learn lessons which can then be applied elsewhere. NHSDW’s clinical governance infrastructure has also been extended across the Trust, dealing with deficiencies identified in the WAO and HIW reports.
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6.7 “Delivering Emergency Care Services” (DECS). Before NHS Direct joined the Trust, 16% of their callers were being triaged to home care and 5% to emergency care. We were encouraged to learn that the equivalent figures for January, 2008, were 37% to home care and 3% to emergency care. Almost 58% of callers are being triaged by NHSDW to safe and appropriate non urgent dispositions, including home care, pharmacy and GP routine. This improvement provides the foundation for the Trust’s contribution to DECS, with its theme of quick and appropriate access to unscheduled care. WAST executives told us that a concerted effort has been made to engage with the various unscheduled care partnership boards across Wales and WAST has identified emerging themes from this engagement. The Trust will continue to work with health communities to support their DECS baseline assessments and subsequent Local Development Plans. 6.8 Information. WAO analysis has concluded that there has been a significant improvement in the quality, depth and accuracy of information available within the Trust through the development of new ICT systems and a strengthened health informatics team. This has enhanced analysis of demand and the development of new rosters, supported by regional teams for production and utilisation of ambulance crew hours. The introduction of ProMis technology and the development of specialist resource centres in each regional control centre should lead to increased efficiency and sophistication in matching the supply of ambulance personnel and vehicles to demand. The Trust will need to continue to develop and refine the quality of information required to support this process as well as monitoring both the acceptance by staff and the efficacy of the new technology. 6.9 Fleet. There has been a significant investment in new fleet and clinical equipment which, in the Review Group’s view, has been received positively throughout the Trust and brought real benefit to both patients and staff. The improvements in this area of the Trust’s business have been welcomed by staff with over 80% expressing satisfaction with the developments, although there have been one or two reservations about the robustness of the vehicles. 6.10 Procurement. Weaknesses in procurement practice identified in the Auditor General’s report have been addressed. Since April 2007 the North Wales Business Services Partnership has taken responsibility for all the Trust’s procurement. This should prove to be a positive step. However, as the WAO has pointed out, the new systems will need to be further tested before a more considered judgement on their effectiveness can be made.
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6.11 Financial management. The Trust has delivered on its financial targets against a difficult background, with a lower projected deficit than was approved in 2007/8. More effective capital and business planning processes are being developed but financial management will remain a key area. Financial information is more robust, reflecting ICT improvements. 7 CHALLENGES REMAIN 7.1 The Review Group concluded on the evidence presented that the Trust continues to face significant challenges in the future. We judged that this was only to be expected at this formative stage of the wide ranging process of transformational change initiated by the Board. 7.2 Regional variations in standards The Review Group recognises that the Trust faces its biggest problems in the South East Region where the volume of work is greatest and where performance levels are most in need of improvement. Significant pressures and demands on operational staff are reflected in the highest levels of negative feedback about the Trust from employees. There have also been difficulties in negotiations with staff on issues such as meal breaks, overtime, rotas and relief. The Trust is aware that concerted action is required to improve the position. A new regional director for the south east has recently taken up his post after difficulties in recruiting to this position. This should provide the leadership needed to address these issues more effectively. The interim HR Director is also located in the region. Whilst performance in the Central and West Region has been satisfactory, there have been some fluctuations more recently which the Trust will need to monitor closely. Powys, which covers a very extensive land mass and has a large number of small, scattered communities, remains the greatest challenge for the Trust if significant performance improvement is to be achieved. 7.3 Staff survey results and issues of morale Staff issues were key concerns for the Review Group. These are listed in Section 4 above and developed in some detail by the Auditor General in Appendix 1. Some of the key messages emerging from the sections in the appendix dealing with staffing matters relate to poor morale, particularly in South East Region, hostility to many of the key changes the Trust is trying to introduce and the need for rapid progress, both in terms of management development and appraisal. The Auditor General also refers to the need for better processes to reduce sickness absence, provide a better work/life balance and engender a culture which would ensure a greater acceptance of the change programme.
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In any programme of major change, it is the norm that achieving cultural acceptance throughout the organisation is what takes longest to achieve and that morale often falls in the initial stages. The Review Group’s feedback from WAST staff has borne this out, with the concerning results of the recent staff survey re-enforced by our own findings. We were not surprised by this, given the extent and pace of the changes being introduced, but we were made very aware of the strength and depth of these feelings of disengagement and the perceptions of unacceptable management practice articulated in paragraph 4.3 above. We identify this as an essential priority for the Trust to address in the next phase of the modernisation plan. There is a need to examine again both management arrangements and management style throughout the Trust. We acknowledge that the Trust has already made concerted efforts in this area and a number of innovative steps have been taken. Nevertheless, there is a wide perception that management is remote and driven by performance rather than clinically related criteria. One of the outcomes of this is the negative perception of management emerging from our consultation with staff and through the staff focus groups. It is vital that the Trust continues to address this issue as an inevitable concomitant of a major change programme. “On the Road” staff remain unhappy with dynamic deployment. This is being examined as part of the Trust’s wider estates strategy and the planned development of a network of social deployment points. We were heartened by the continuing overall commitment of members of staff to the service and their willingness to adapt to change for the benefit of patients. They must be given the support to do this effectively. 7.4 Education and Training 7.4.1 Management capacity and development Crucial to the successful engagement of staff at all levels is a strong programme of management development at all levels and again, in the view of the Review Group, this should be accorded priority status. Further early progress must be made to improve the quality of immediate line management. The cultural concerns previously identified make this absolutely essential. Overall management capacity is also a concern in the context of the size of the modernisation task. The roll out of the Clinical Team Leader role needs to be accelerated. The Trust is aware of the importance of this. Priority also needs to be given to Trust wide introduction of appraisal. 7.4.2 Paramedic Development We noted that the Trust is expanding its education and development programme, including university accreditation, to provide its paramedics with the skills and
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capacity to assess, treat and refer patients in appropriate cases without transporting them to hospital – particularly important in sparsely populated areas where delivery of performance standards will always remain challenging. This is part of the wider agenda of developing clinically safe systems to ensure the most appropriate use of EMS in responding to patients with life threatening conditions. 7.4.3 Technicians We noted that the Trust remains committed to developing the role of the ambulance technician within the service in Wales. This is in contrast to England where the trend is to support paramedics with emergency care support workers who are not trained to the same level and who are paid on a lower scale. 7.5 Deployment of Rapid Response Vehicles The Review Group concurred with the Trust’s case that the deployment of Rapid Response Vehicles (RRVs) has made a demonstrable contribution to the improved emergency response times and with it an improved outcome for patients. However, we recognised that concerns remain, both within the service and anecdotally amongst the wider public, about the efficacy of back up arrangements. There have been some instances where there have been unacceptable delays. This has led to questioning of the usefulness of RRVs, but the evidence shows that they are providing a valuable contribution to overall emergency response performance. This is demonstrated by the performance improvements indicated in the table showing improving compliance with the Category A14/18/21 standard in paragraph 6.2. The WAO analysis in Appendix 1 (point 1.9) notes that in most LHB areas there was improved performance in relation to back up of the Trust’s initial response with a fully equipped ambulance to take patients to hospital. Part of this improvement was as a result of the discontinuation of the so called “Directive 66” which allowed RRV paramedics to decide whether or not they needed ambulance back up – this is now automatically despatched. Our review concurred with the Auditor General’s findings that, in most cases, the use of RRVs has not been at the expense of ambulances being available to take patients to hospital. The Trust sends timely ambulance back up to the initial response on most occasions. There are, however, a small minority of calls, mainly in south east region, where there are excessive delays, particularly in relation to Category B and C calls (see Appendix 1 Para 1.10).We understand that the Trust leadership is aware of this and regards the issue of effective and timely back up as vitally important. It must continue to address this in a robust manner, including those whole system challenges cited in this review which act as an impediment.
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7.6 Excessive Turnaround Times We have noted earlier in this review the steps that the Trust has taken with its NHS partners in addressing the issue of hospital turnaround times. Nevertheless, these delays remain a significant risk to clinical safety, adversely affect the Trust’s planning assumptions and compromise its ability to match supply with demand. This is an NHS wide cultural problem of an inherently cyclical nature which the Trust must continue to address as a priority. We commend both the partnership approach adopted and the introduction of the new targets. As well as tackling difficulties with the admission of patients to acute care, the proper planning of discharge arrangements is also an important variable. 7.7 Matching Supply and Demand The Review Group noted that the analysis which had been introduced in order to match staffing levels with the expected demand for emergency ambulances was regarded as sound in methodology by both the WAO and the Review’s academic adviser. However, we remained concerned that its practical application had not been accepted by staff as realistic. This was accompanied by staff reservations about the balance between RRVs and double crewed ambulances. It is vital that the Trust engages with staff to explore these areas of difference as the Review Group is convinced that it is the conflicting views in this area that lie at the heart of the major disagreements between management and staff. 7.8 Achievement of an estates strategy which supports the modernisation plan The Review Group had remaining concerns in this area in particular in relation to the rate of progress but we noted that changes in line management arrangements and a strengthening of the estates team had recently been put in place. This should assist in the successful development of a coherent estates strategy which needs to be linked to the development of new models of unscheduled care which form an important part of the Trust’s modernisation plan. We would emphasise the need for early progress with the Trust’s proposals for “Make Ready” stations, which we believe will bring real benefits, both to the deployment of fully crewed vehicles and in relation to infection control and the cleanliness of ambulances. Additionally, the Trust must make a robust case to secure funding to address basic statutory responsibilities which will be identified as part of a re-survey of its estate. The completion of the Trust’s Strategic Outline Case for capital support for its long term estates strategy will be a positive step in this direction. 7.9 Financial risks The review group recognised that there are financial risks associated with the SCEP and the cost improvement target. The Trust’s plans assume ongoing WAG
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support with capital charges which are relatively high for WAST because of the short life cycle of vehicles. The SCEP also includes proposals to provide unscheduled care services to other parts of the healthcare system and it is essential that these are achieved. In addition, the new models of providing care arising from DECS will require new financial mechanisms to manage the implications and financial flows affecting WAST. Other risks include the availability of funding to deliver the full benefit of technological developments such as the Ambulance Radio Re-procurement Programme (ARRP) and more stringent performance targets, particularly when these are locality based. There is a direct correlation between population sparsity and the cost of achieving performance equality, because of the resource intensive nature of providing cover in rural areas of large size and relatively few people. We would like to see a closer link between a clear medium term capital investment plan and the achievement of performance improvement. Finally, the Trust must make a robust case to ensure that its discretionary capital allowance matches its ongoing vehicle replacement programme. 7.10 Locality targets The Review Group noted a continuing variation in performance among LHB areas, though there has been an improvement in the number of areas which were achieving the 60% standard since February, 2007. Better performance is evident in most areas. Difficulties were most acute in the rural areas of Powys and Monmouthshire but the spread of performance is much better than it was at the time of the Auditor General’s original report. From 1st April, 2008, the Trust has been asked to respond within eight minutes to 60% of all Category A calls in each LHB area in each month. This is designed to achieve greater equity of response. The Trust supports this aim but remains in discussion with WAG regarding its operational and financial implications. Although there may be financial and operational issues to be addressed, the Review Group fully supports the move towards equity, recognising that the current spread of performance across the LHBs is neither acceptable nor sustainable. The Community Health Councils, whilst expressing concern about the difficulties of maintaining performance in rural areas, have stressed that their overriding priority is a good outcome for the patient. This is a priority shared by the Trust. 7.11 Implications of reconfiguration The Trust, with its partners, will need to address the implications of the organisational reconfiguration on which consultation is currently taking place. This will test existing management capacity which is stretched in meeting the demands of a challenging change management programme accompanied by high levels of external scrutiny.
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THE MODERNISATION PLAN 8.1 Professor Morton Warner of the Welsh Institute for Health and Social Care was asked to provide an independent assessment of the Trust’s modernisation plan “Time to Make a Difference (TTMD) and its continuing fitness for purpose. Professor Warner has met with all of the Trust’s Executive Management Group and has undertaken detailed discussions with the Programme Management Team charged with the management of the TTMD and its implementation programme. In addition, he joined the chairman in several meetings with stakeholder groups including one with staff side representatives. 8.2 Professor Warner drew fifteen important conclusions as a result of his study. They are included in his full report attached as Appendix 3 to this review. These are as follows:-
• WAST formulated a best practice approach to initiating action at the first developmental stage of “Time to Make a Difference”;
• opportunities were missed to engage managers amongst field staff at an early stage;
• given the range and complexity of the project work to be undertaken and the need to introduce discipline to the process, the inception of the Programme Management Group was a necessity and WAST is to be commended for taking such a move in the face of a budget deficit and immediate operational demands;
• it is understandable that WAST is seeking, with some success, to put its own house in order first, but it now needs to work more horizontally and actively at all levels through developmental partnership arrangements, and support those personnel who do so engage;
• whilst acknowledging the deficit situation in the Trust, the misalignments between project capital investment, human resource availability and training will, in the short term, lead to frustration on the part of staff and, in the medium term, to performance failure;
• a trained human resource is a key success factor in implementing TTMD projects and the risks of the failure in investments in this respect require active management;
• with the advent of more exacting business cases, output management has been given more prominence. This is to be commended; but organisational processes should be proposed in greater detail, as well as funding, human resources and training commitments;
• failure to bring together the work of the various project group networks will result in wasted opportunities for synergies and, potentially, less efficient and effective activities;
• TTMD project networks constructed by Executive Directors and the Programme Management Department are not sufficiently inclusive and
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representative of knowledge from all levels of WAST. Regional Directors are not sufficiently involved in constructing an active membership;
• WAST is to be commended for having assembled a capable top team and a regional management tier fit for the purpose of implementing TTMD;
• Regional Directors, working in line with national templates, have not, for a variety of reasons, been able to exercise sufficient autonomy in terms of sub regional planning for the provision of services, for example the use of RRVs and their manning;
• the demand profile methodology is not well understood and its results do not accord with the observations of many personnel on the ground;
• management training and other investment at local levels is lacking in relation to the lynchpin role to be played by the Locality Ambulance Officers in making TTMD happen on the ground; full strategy penetration will not happen until proper, consistent and well understood subsidiarity arrangements in relation to authority and autonomy are put in place.
• Local Health Boards view WAST as having made good progress on TTMD but are concerned for the Trust’s capacity to move forward further with the necessary momentum;
• Local Health Boards recognise that major issues that are the responsibility of other organisations in the NHS to solve do have damaging knock on effects on WAST.
8.3 In the light of the above, Professor Warner has made the following recommendations aimed at improving the Trust’s programme management arrangements. These are endorsed by the Review Group:-
• an extended programme approach should be introduced through the development of a clear strategic intent for the organisation, communicated and owned by all;
• all relevant activities should be directly related to a health or social gain;
• the Trust should re-affirm its commitment to high quality project management and a dedicated programme management capacity;
• the importance of proper integration across projects should be given greater emphasis
• mandatory involvement at all levels must be embedded in project groups to ensure application of relevant knowledge and improve ownership throughout the organisation;
• planned partnership with the wider NHS must be fundamental; • projects should only be approved against the background of
identified human resources, training and funding; • an urgent review of authority and autonomy models in the
implementation of TTMD; • investment in locality ambulance officers to better equip them to
carry out their TTMD responsibilities.
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9 INFECTION CONTROL AND THE CLEANLINESS OF AMBULANCE VEHICLES 9.1 Dr Nick Looker of the National Public Health Service kindly agreed to provide expert advice on this very important aspect of the terms of reference. In doing so, he conducted a series of visits to all three regions of the Trust to observe the application of current practices and procedures, whilst also meeting key managers as well as staff side representatives. In addition he has met Clare Cookson, the Trust’s non executive lead on infection control and the National Fleet Manager, who is responsible for implementing the Trust’s long term plans for “make ready” depots which will further improve the Trust’s capability in this area. 9.2 Dr Looker identified a strong and positive commitment to infection control and a culture supporting improvement of this at the highest levels within the organisation. He also concluded that the overall governance framework was sound for monitoring and development of effective infection control. There was a clear commitment on the ground to high standards of hand hygiene, the most important single contributor to good infection control and the new generation of ambulance vehicles was well designed from this perspective. 9.3 Against this background, Dr Looker was able to make a number of important recommendations aimed at effecting Trust wide improvement in infection control practice and the cleanliness of vehicles. His full report is attached as Appendix 4 to this review but, in summary, Dr Looker has recommended that:-
• professional infection control and advice is engaged at a national level; measures are taken to develop communication links at regional and local level with hospital and community infection control staff; consideration is given to the need for local/regional infection control leads;
• consistent occupational health arrangements are made across the Trust. These should include the delivery of staff immunisation requirements and appropriate screening arrangements for new members of staff taking into account revised UK Health Department guidance;
• the Trust must ensure that issues identified by the Infection Control Working Group (ICWG) or Clinical Governance Committee are reflected operationally via locality ambulance officers and clinical team leaders; review of relevant complaints and incidents should be part of ICWG’s remit, including sharps injuries;
• appropriate access to facilities and storage in A&E departments should be agreed with local trusts; arrangements should be put in place to ensure the Trust is consulted on plans for new or refurbished A&E facilities;
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• the Trust develops an annual infection control and reduction programme based on relative risks; all current policies and procedures are reviewed on a regular basis; a review of the use of personal protective equipment is also undertaken;
• training arrangements are reviewed against the background of current good practice;
• the Trust should further examine cleanliness issues on new vehicles to improve already acceptable standards, including the provision of sufficient time to ensure the necessary decontamination. Implementation of the “make ready” system will be helpful in this regard;
• the Trust should ensure a high minimum standard of basic facilities at all stations.
These recommendations will underpin the Trust’s approach to infection control in the future.
