Written Statement - Update on progress since introduction of the Clinical Response Model and Accelerated Programme for Amber Review (APAR)

In October 2015, we took the bold step to adopt an innovative new model that significantly changed the way ambulance services in Wales are delivered. The changes were first piloted in response to Professor Siobhan McClelland’s Strategic Review of Welsh Ambulance Services (2013). In February 2017, following a successful 18-month pilot, I confirmed that the model would be fully implemented.

The clinically driven changes introduced under the new model are ensuring patients receive the right response based on their clinical need and since the new model was first piloted, the Welsh Ambulance Services Trust (WAST) has been able to demonstrate significant improvements in the response times for the highest priority ‘Red’ calls. This is not about hitting targets to give the appearance of an improved service and at its heart, the model is about transforming the quality of care delivered to patients.

These changes are making the emergency ambulance service in Wales among the most progressive in the world. It was encouraging that the independent evaluation of the model concluded not only that moving to the new model was the right thing to do, but that it has helped to deliver a service that is more focussed on the quality of care patients receive as well as improving efficiency in the use of ambulance resources.  The model has also attracted UK-wide and global interest from ambulance services, wishing to emulate our success, with new models very similar to our own being introduced in England and Scotland.

That said, neither we, nor the Welsh ambulance service, are complacent. We recognise that while the model rightly prioritises those in most need of an immediate response, some lower acuity patients have, at times over winter, waited longer than we would expect. In order to continue to deliver the very best response to patients, services must be kept under constant review.

The independent evaluation of the clinical response model made a number of recommendations for further improvement to ensure the model continues to deliver a safe and clinically appropriate service to patients. I am pleased to report progress has been made against all recommendations. A key recommendation was that a review should be undertaken of the call categories outside the ‘Red’ (immediately life threatened) category.  A review of all Amber prioritisation codes undertaken by the WAST Clinical Prioritisation Assessment Software Group (CPAS), which includes internationally renowned experts in prioritisation, the Chief Ambulance Services Commissioner and senior ambulance clinicians, determined that the allocation of codes to the new categories remains clinically appropriate. Furthermore, the configuration of codes in Wales is almost identical to versions of the clinical response model introduced England and Scotland.

In order to make sure patients continue to get the most appropriate and best level of care and treatment for their needs, WAST will ensure the new call categories are kept under constant review.

The evaluation also concluded that investment in information systems would provide opportunities to both enhance and make more seamless the call management and dispatch process as well as providing more robust information to support further service development.

In November 2017, with the support of £4.48m of Welsh Government capital funding, the Welsh ambulance service upgraded its existing Computer Aided Dispatch (CAD) system to a state of the art system which has enabled substantial improvement in the planning and faster dispatch of ambulances to patients.

The evaluation also recognised that in recent years, the role of the ambulance service has evolved away from simply taking people to hospital.  Now its role is to intervene earlier in the patient journey by resolving calls through telephone assessment (hear and treat) and to treat more people at scene (see and treat), reducing the number of avoidable ambulance journeys and allowing the ambulance service to concentrate its efforts on responding to the most life-threatening cases.

We have seen a marked increase in ‘hear and treat’ and ‘see and treat’ rates following an investment of nearly £700,000. This has enabled the Welsh ambulance service to increase the number of clinicians working on its clinical support desk, which ensures fewer patients are sent an ambulance response or conveyed to hospital when they do not need further care or treatment. Between 01 January 2018 and 31 March 2018, 17,990 ambulance journeys were avoided following telephone or face-to-face assessment at scene, enabling these patients to remain in their own homes and freeing up ambulance resources to respond to other urgent calls in the community.

Resources are also being invested to deliver care closer to home through local admission avoidance schemes; the use of paramedics, nurses and GPs working in clinical contact centres to provide secondary clinical triage over the telephone to ensure patients receive the right response based on their needs; and a number of community paramedic models being trialled across Wales to explore opportunities for paramedics to support primary and community care services.

WAST clinicians are also working in police control rooms to provide clinical advice and support by telephone to police personnel attending incidents which may require an ambulance response. This has resulted in reduced demand on ambulance services and freed up ambulance and police resources by preventing avoidable ambulance journeys.

The Ambulance Quality Indicators (AQIs) introduced to support the model are placing an ever greater focus not only on the timeliness of the response, but on the appropriateness and quality of the response people receive. They are providing further assurance that patients who are no longer subject to a simple time-based target will receive a safe and timely response to their clinical needs. I have been particularly encouraged by the high performance levels against the 7 clinical indicators, which demonstrate that paramedics are delivering care that makes a real difference to patient outcomes. WAST is committed to introduce four further clinical indicators within the next 12 months.

These indicators have also enabled an improved understanding of the service delivered to people with certain conditions. An audit of responsiveness to stroke patients is being undertaken for each stroke receiving unit in Wales by EASC. This will provide a snapshot of patient level information at each site in Wales and provide assurance on response to this type of incident.

Work is also ongoing to link ambulance patient-level information with emergency department patient-level information to enable collection of clinical outcome information and better describe the impact of responsiveness / quality of ambulance clinician care. This will further support WAST in ensuring it continues to deliver a safe service to patients to optimise patient outcomes.

In light of the progress outlined above, the Emergency Ambulance Services Committee (EASC) agreed at its meeting on 27 March 2018 that the independent review recommendations had been discharged and could now be closed given there were six work streams established to deliver or oversee progress that had now concluded or were ongoing for an indefinite period.

Building on this existing work, the Chief Ambulance Services Commissioner has commenced a clinically led review specifically on the Amber category to further improve ambulance responsiveness, clinical outcomes and patient experience.

The review will look at:

• The current state in respect of extant policy, practice and guidance, activity and measures and risk
• Expectations and experiences of the public, staff and the wider service around ambulance response to Amber calls
• Consideration of environmental factors such as location of incident / age of patient etc. when determining allocation of a response, and
• Other internal or external factors which may contribute to / impact on how WAST responds to ‘Amber’ category calls.

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. They will be consulted as part of the review. In order to ensure all relevant views are considered as part of the review, stakeholders will include members of the public, staff (including trade unions and the college of paramedics), operational managers across NHS Wales organisations and Assembly Members.

I have asked the Chief Ambulance Services Commissioner to provide me with the final review report in early September, to support delivery of recommendations as early as possible. I will then make an oral statement to inform Assembly Members on the review’s findings and recommendations.

The Emergency Ambulance Services Committee has released a public statement regarding progress made since the publication of the independent evaluation report on the clinical response model and detailing the planned review of Amber calls which can be viewed at the following link:

http://www.wales.nhs.uk/easc/news/48190