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Written Statement - Progress against McClelland Review recommendations

Vaughan Gething, Deputy Minister for Health

Professor Siobhan McClelland’s Strategic Review of Welsh Ambulance Services, which was published in April 2013, made a series of recommendations about the delivery of ambulance services in Wales.

Since its publication, work has been undertaken to implement its recommendations – including appointing a new Welsh Ambulance Services NHS Trust (WAST) board – to transform the Welsh Ambulance Service into a clinically-responsive service at the heart of our unscheduled care system.

Changes introduced to the Welsh Ambulance Service over the course of the last 12 months include:

  • A clinical desk, staffed by an emergency department consultant, paramedics and nurses, has been introduced to clinical control centres to review 999 calls as they come in ensuring those patients who need a fast response receive it;
  • Alternative care pathways for patients who do not require an emergency ambulance response have been developed and rolled out across Wales. More than 8,000 patients have been referred to healthcare settings other than an A&E department to date; and
  • More than £4m has been invested in high-tech equipment for ambulances, including defibrillators and additional pain-relieving drugs to enhance survival rates and improve patients’ clinical experience.

The Welsh Government will invest a further £1.1m to equip all frontline emergency ambulance staff with digi-pens. These will allow paramedics to digitally manage and track patients' care as they move through the emergency care system.

The McClelland review was clear that a clinical vision for emergency ambulance services should be central to ambulance reform and that any changes to the way the service is governed, funded and structured should flow from this.

This is being delivered by health board chief executives as members of the emergency ambulance services committee (EASC) – a joint committee of health boards. It ensures health boards are accountable for planning and commissioning of emergency ambulance services. Previously, the Welsh Ambulance Services NHS Trust was solely responsible for planning and providing ambulance services in Wales.

To strengthen these arrangements, Stephen Harrhy, the former director of the Welsh Health Specialised Services Committee, has become Wales’ first chief ambulance services commissioner. He will ensure that the health boards own the delivery of emergency ambulance services and help to identify areas of service improvement for the Welsh Ambulance Service.

In less than a year EASC, under the chairmanship of Professor McClelland, has: 

  • Allocated £7.5m in recurrent funding to recruit 119 frontline staff, with 107 appointments made to date;
  • Provided a further £8m to support delivery of emergency ambulance services during the challenging winter period;  
  • Designed a commissioning and quality framework for 2015-16, which includes a range of patient care standards and will provide context to the quality and timeliness of care being provided by pre-hospital clinicians.

The McClelland review clearly highlighted there is little clinical evidence to support the eight-minute response time target for the vast majority of 999 calls, which are currently classified as “life threatening”. 

The eight-minute response time target was initially developed in 1974 and does not reflect the breadth of clinical care ambulance clinicians are able to provide at the scene of an incident and before a patient reaches hospital – in many cases a patient may never need to go to hospital. The ambulance service has moved on significantly in the past 40 years but the way we measure the quality of service delivery has not. 

To better reflect the quality of care being delivered by pre-hospital clinicians we have carried out experimental work on new clinical indicators which describe the care provided to patients suffering from stroke; STEMI (a type of heart attack); and fractured hips.
These reflect the critical role paramedics play in the treatment of a sick or injured person. The results of this work show that 95% of stroke patients are receiving a specific package of care measures from paramedics in Wales and 86% of patients with a fractured hip received immediate pain relief in line with clinical guidelines in 2014-15. 
In line with the McClelland recommendations and as a result of increasing demand for information about category A calls, Welsh Government statisticians will publish more data as official statistics to complement the existing contextual statistics, which are available every month.

Information relating to ambulance responses to those patients who are classified as having the most life-threatening conditions, where there is clinical evidence to support an eight-minute response – known as Red 1 calls – will be included in the official ambulance response statistical release from March 25. 

This is part of an ongoing review of how we measure and report on the quality and effectiveness of our emergency ambulance services. 

Following the announcement of two ambulance response time pilots in England and after receiving representations from the medical director of the Welsh Ambulance Service about the clinical validity of the eight-minute target, Wales will also test new ambulance response measures for category A calls. These will be developed in conjunction with clinicians and will be informed by the approach taken in England. I expect to receive further advice from clinicians about making best use of resources and improving clinical outcomes in coming weeks.

It is our ambition in Wales to create a supply of high-quality, home-grown pre-hospital clinicians, educated and trained at Welsh universities. To support this, the Welsh Government is investing in the next generation of paramedics. The number of places on the one-year conversion course will increase by 50% and there will be a 300% increase in the number of diploma-level paramedic places in the 2015-16 academic year in Wales.
The McClelland Review recommended that work should begin to transfer patient transport services – known as patient care services – out of the ambulance trust and give responsibility for their delivery to health boards. In taking this aspect of the review forward, any planned changes must ensure the ambulance trust does not lose focus on delivering a clinically-led emergency response service.

The health boards and ambulance trust have been exploring a range of options for the transfer of health courier services, which provide a wide range of services to support local communities, local health groups and GPs. The NHS Wales Shared Services Partnership will take over health courier services. 

In view of the complexity, clinical concerns and challenging workforce issues associated with transferring patient care services, their future will be considered as part of a wider modernisation programme. This will take account of the extent to which these services will be disaggregated from the emergency ambulance service. 

Transferring elements of the patient care service must result in better use of resources for those people who need non-emergency transport but also in an improvement in the clinical performance of the emergency ambulance service.

Performance against the existing eight-minute response time target is disappointingly not where the Welsh Government, the Welsh Ambulance Service, health boards or the public would want it to be, however significant progress has been made in implementing the McClelland recommendations and transforming the ambulance service from a transport service into an emergency clinical service.