In June 2005 the Department of Health published ‘Taking healthcare to the patient’. This followed a 12-month review of the role of the ambulance service in England. The report made 70 recommendations across a wide range of operational, financial and workforce issues. All were focussed on ensuring that the service was best placed to deliver appropriate and timely care to patients needing urgent or emergency healthcare. The ambulance service, by increasing the clinical skills of its staff, would take a far greater role in delivering healthcare in the modernised NHS.
Increased capability and capacity
A major recommendation within the review was that to take on this wider role the capacity and capability of ambulance services would have to increase. Since their transfer to the NHS in 1974 ambulance services have been through a series of reconfigurations. In the 1990s a number of the mainly county-based services had been amalgamated to form regional services, for example in East Anglia. However, this process had never been completed and the majority of services remained county-based. Although some were sizeable organisation such as Greater Manchester others such as Cumbria were relatively small. Work was underway from early 2005 on bringing together the services in Avon, Gloucestershire and Wiltshire which merged as Great Western Ambulance Service from 1 April 2006.
Left with a decision on the rest of England, the Department of Health published proposals in late 2005 recommending that the other 27 ambulance services in England (excluding that in London which was already the largest public ambulance service in the world) should be reconfigured to match the existing Government regions that already existed for planning and other purposes (and became the model for the reconfigured SHAs in 2006). Ministers announced in May 2006 that the proposals had been accepted in most parts of the country and that from 1 July 2006, a further nine regional ambulance trusts would be established. These were to be:
North West (covering Cumbria, Lancashire, Merseyside, Greater Manchester and Cheshire); North East (Northumberland, Tyne & Wear, County Durham and Cleveland); Yorkshire (Yorkshire and Humberside Region but excluding the south side of the Humber); East Midlands (Derbyshire, Nottinghamshire, Leicestershire, Rutland, Lincolnshire, South Humberside and Northamptonshire); West Midlands (Shropshire, West Midlands, Warwickshire, Herefordshire and Worcestershire); East of England (Cambridgeshire, Norfolk, Suffolk, Essex, Bedfordshire and Hertfordshire); South East Coast (Kent, Surrey and Sussex); South Central (Buckinghamshire, Oxfordshire, Berkshire and Hampshire); South Western (Dorset, Devon, Cornwall and Somerset).
Outside of this structure were the Isle of Wight where Ministers decided that it would more appropriate to leave the service as part of the single health trust on the island. They also decided, following a strong campaign by local politicians and the community in Staffordshire, that the service in that county should remain though with the intention of merging it with the enlarged West midlands at some point in the future.
Running parallel to the consultation period, the Department of Health and the NHS Appointments Commission had identified a pool of suitable candidates to take on the posts of chief executives and chairs of the new services if the decision was made to go ahead with reconfiguration.
As a result it was possible for those selected to take on acting roles with the shadow trusts almost immediately. Furthermore, each of the new chief executives was already an ambulance trust chief executive, in most cases for a service within their new region, and seven of the nine chairs had been chair of an existing ambulance service. Given that there were only seven weeks between the ministerial decision to go-ahead and vesting day, this was undoubtedly a considerable help in ensuring that the new organisations were ready to go on 1 July.
Almost six months on from the establishment of the new trust, or nearly nine in the case of Great Western, the new organisations are now key players in providing healthcare within their regions. Most of the senior management teams for the trusts have now been appointed but there are clearly considerable challenges remaining in bringing together a number of established organisations covering large populations and areas and employing substantial workforces. At the same time local links need to be maintained with the many partners and stakeholders who have interdependence with the ambulance service. Local managers, keeping and developing those links with their communities, are a vital part of the new ambulance structure.
The new NHS is changing the way in which it helps people with their healthcare needs. Whether the need is a sudden emergency or management of a long-term condition, the aim is trying to provide care in the most convenient location for the patient and avoid unnecessary hospital admissions and visits. A succession of recent Government policy papers including the January 2006 White Paper ‘Our health, our care, our say’ and ‘Direction of travel for urgent care’ published in October 2006 have confirmed this intention. The ambulance service is at the hub of the system that can deliver this policy.
The traditional response of the ambulance service to a 999 call of always sending an ambulance and usually taking the patient to hospital is no longer appropriate. New technology is helping call takers make very fast and safe decisions on the best way to help each caller.
For some an ambulance responding on blue lights may still be appropriate, but for others, probably a majority of the 5 million 999 calls received by the ambulance service in England each year, telephone advice, an ambulance clinician visiting the patient on a non-emergency basis or referral to another agency may well be far more effective. Clinical guidance for ambulance staff is provided by JRCALC. The fourth edition of the JRCALC guidelines have recently been published giving concise, best-practice advise to staff in almost every conceivable area from child protection to quick guides for drug dosages.
A major task for the ambulance service over the next couple of years will be to ensure that its work is clinically focussed. Audit, although widespread in other areas of healthcare, is not so well embedded in the ambulance service. Some significant progress has been made over the last couple of years with national audits, co-ordinated by the ASA, of the response to heart attacks and cardiac arrests. Participation in these audits is not a core performance measure for ambulance services in their annual Healthcare Commission Healthcheck. Expansion of the audit capability will be a key task for all services over the next five years.
Many of the other recommendations from ‘Taking healthcare to the patient’ are focussed on making sure that the services are capable of offering this much more responsive service. This will require many changes. Existing workforces will have to learn new skills, but the experience of recent years as new drugs and other interventions have been authorised for use in the pre-hospital setting have shown just how supportive staff are of change that will deliver improved patient care.
Helping patients with long-term conditions to manage their own health in their homes and prevent acute episodes that could require a trip to hospital is a key part of current policy. The ambulance service is taking its part in helping this objective both by identifying the wider needs of patients to whom it responds and by providing mobile clinic services visiting patients in their home to deal with issues as diverse as taking blood samples or helping patients with their longer-term following discharge from hospital after a heart attack.
Services are training existing paramedics and, in some cases nurses, to take on the role of Emergency Care Practitioner. ECPs have an extended education to enable them to make judgements about the best pathway forward for patients with less obvious presenting symptoms. This is an exciting role for ambulance clinicians offering them far broader experience of patient care and it is likely that thousands of paramedics, and perhaps others, will take on these roles over the next few years.
Digital radio network
Ambulance services are already very sophisticated communications and logistics operations. In their new roles they will have to become even cleverer at getting this right. The new services are reviewing their control room structures. Fortuitously the reconfiguration coincides with the start of roll-out for the new ambulance digital radio network which will offer a far more effective and resilient system for both voice and data transfer than services have had in the past. The new system should be operational across the country within a couple of years.
The Department of Health already demands fairly exacting performance standards from all ambulance trusts. The most widely quoted is the requirement to get clinical aid to the side of any patient assessed as having a potentially-life threatening condition within eight minutes in 75 per cent of cases. With 32-33,000 such cases each week, this target is almost being met with a typical week showing performance at between 74 and 75 per cent. However, the target is being tightened as from April 2008 the eight minutes will be measured from the point at which the 999 operator connects the call to the ambulance service. Substantial work will have to be done by all services if that new standard is to be achieved.
The ambulance service is the emergency arm of the NHS. In addition to dealing with the thousands of patients who turn to it every day, the service must always be prepared for major incidents. These could include incidents caused by severe weather, major outbreaks of illness such as the flu pandemic that the epidemiologists tell us is now overdue, industrial or transport accidents and, sadly, the terrorist threat.
The 2004 Civil Contingencies Act made ambulance service Category 1 responders with considerable legal responsibilities to prepare for emergencies but with a seat at all the forums that are ensuring that the country is as prepared as possible to cope with whatever is thrown at it. The larger size of the new trusts undoubtedly means that the ambulance service is better able to undertake this role should the occasion arise.
In some ways the enhanced role of the ambulance service has perhaps happened a year or two later than would have been ideal. The process may have been easier if had happened at a time when the significant year-or-year funding increases for the NHS were happening rather than now when the financial constraints are getting tighter and tighter. However, as a smaller group some economies of scale may be achievable by more intelligent procurement and this is an important stream of work over the next few years. Commissioning and payment by results are exercising all trusts and will again be a further key area of work.
In the medium term most trusts see significant opportunities from becoming foundation trusts. The current rule of eligibility for applying to Monitor mean that progress is unlikely for another couple of years, but as soon as the go-ahead is given, several trusts will be pushing hard to gain that status.
Ambulance services are going through a rapid period of change. Reconfiguration is just one element of that change. Looking forward just a few years they will look, feel and act very differently to how they have traditionally. As a result the care and support they give to those who call on them will be far more appropriate.