Written Statement - The Independent Evaluation of the Emergency Ambulance Services Clinical Response Model

I am pleased to have an opportunity to update Assembly Members on the Welsh Ambulance Services NHS Trust’s (WAST) clinical response model pilot following receipt of the independent evaluation report commissioned by the Emergency Ambulance Services Committee (EASC).

Members will be aware of the decision I made in summer 2015 to test an innovative new operational model that significantly changed the way ambulance services in Wales are provided to patients. This was a decision based on substantial clinical advice from leaders across NHS Wales and associated professional bodies. The intention was to:
 

•  deliver a more clinically focussed service that prioritised people who would most benefit from an immediate response to optimise outcomes;
• allow clinical contact centre call handlers more time to discern the type of response required based on patient clinical need in order to enhance patient experience and outcomes by enabling patients to get to the right clinicians earlier – crucially reducing the level of unnecessary multiple vehicle responses to patients; and
• introduce a new measurement system based on clinical evidence that would provide more context to the care provided by ambulance clinicians and help to eradicate perverse behaviours created by chasing of a target to the detriment of patients.

The clinical response model pilot commenced in October 2015 and after twelve months I announced there would be a six month extension until March 2017 to enable further time to complete a comprehensive independent review of its impact. Members will be aware that our pilot has garnered global interest and WAST has not only been invited to provide advice to a number of ambulance services in England and Scotland, but further afield to Canada, New Zealand, Australia, USA and Chile. The Scottish Ambulance Services Trust is currently undertaking a nationwide pilot of a very similar model to our own.

Professor Siobhan McClelland sent me a copy of the final evaluation report at the beginning of February. The chair of EASC has made the report publically available through the following web link:

http://www.wales.nhs.uk/easc/publications

I am pleased to confirm that the independent evaluation team found there to be clear and universal acknowledgement, both from within the ambulance service and external partners, that moving to the new clinical response model was appropriate and the right thing to do. The report states the change to increase the time permitted for call categorisation for non-immediately life threatening calls has not introduced any new risk to patient safety beyond those inherently associated with delivery of emergency ambulance services. The independent review team has also been clear that it is likely there would have been significant risk for patients, particularly over winter, without the change to the new model given the increasing demands on our ambulance service.

From a quality and safety perspective, the report concludes there have been no serious safety concerns as a result of the introduction of the new model, with key indicators for reporting of serious adverse incidents and the level of 999 re-contact rates remaining stable or declining.

The report also confirms that response time performance for those in most need of an immediate clinical intervention has improved substantially. The latest ambulance statistics published last week confirm this with a typical response time to those in danger of loss of life or limb reported at less than five minutes.

Importantly, we now know that fewer resources are being used per incident, regardless of call categorisation, meaning patients are more likely to receive the right response capable of providing the right clinical support first time.  This might require a response from a paramedic in a Rapid Response Vehicle (RRV) or an emergency ambulance for some calls, while people with lower levels of healthcare need are increasingly being managed by  clinical telephone advice.

We also know that more resources are being invested to deliver care closer to home and ensure fewer patients are sent an ambulance response when they do not need further care or treatment from the ambulance service. Again, this means essential ambulance resources are being conserved for patients in most need of an immediate response.

An example of this success is the investment in paramedics, nurses and GPs to provide a secondary clinical assessment over the telephone to ensure patients receive the right response based on their needs. Investment in this area has seen a 70% increase in ‘hear and treat’ rates.  These patients are safely discharged over the telephone with no further intervention from the ambulance service required. I expect WAST to work with Local Health Boards through the collaborative commissioning process to invest in initiatives like this, where we have prudently and safely avoided admission of people to hospital.

It is extremely encouraging to note there is agreement that the new model is right for Wales and it has made the service much more clinically focussed.  Demand management has also improved with a better use of resources to the benefit of patients.  The evidence of the independent evaluation adds to the support for the new model from staff and clinical leaders.   I am also aware of the evidence provided by the quarterly Ambulance Quality Indicators report.  I have considered the evidence available and decided to approve the substantive implementation of the clinical response model with immediate effect.

However, it is essential we focus on the opportunities outlined in the independent evaluation for further refinement and improvement.  That includes keeping the clinical response model under constant review. I have written to Professor Siobhan McClelland, chair of EASC and directed the committee to develop a way forward in response to the report’s recommendations, with the Chief Ambulance Services Commissioner in collaboration with WAST. It is important that citizens and staff have an opportunity to contribute to further developments through their understanding of using and delivering these essential services, and to enhance the experience of all who access them.

One area on which I have sought specific advice is the threshold for the performance target for patients described as immediately life threatened. We will need to carefully consider the evidence to properly consider if there are alternative measurements capable of providing sufficient assurance on quality and timeliness of responses across a broad spectrum of conditions.

It is crucial that we grasp the opportunity and continue to lead the way internationally in this important area. In driving forward further enhancements to the model we must continue to act innovatively and courageously.  We will continue to be guided by the very best clinical evidence and advice on how we can continue to improve patient outcomes and patient experience.

I will provide further detail on this decision through an oral statement to Assembly Members tomorrow.