Transforming Welsh Ambulance Service: scrapping times, supporting - PowerPoint PPT Presentation

Transforming Welsh Ambulance Service: scrapping times, supporting patients! Dr Brendan Lloyd Medical Director Welsh Ambulance Services Trust Founding Senior Fellow FMLM

Dr John Kotter: “Leading Change” 8-stage process to creating major change

Our ‘Burning Platform’ - 2013 Operating Context • Increasing demand and acuity • Financial constraint / resourcing gap • Deteriorating performance • Flawed operating / performance model • Frequent senior management turnover • Weaknesses in corporate governance • Challenging industrial relations climate • Talented but disengaged workforce • Intense political and media scrutiny • Repeated review and re-organisation • Doubt about the organisation’s future

The Problem: Contacts 2013/14 • 999 – 420,000 calls CALL TYPE CATEGORY & CODE (MPDS) RED 1 (~3%) • 40% or 166,000 RED 1&2 ≤ 8 min (Echo and high end Delta codes ) CATEGORY RED 2 (~35%) • A 86,000 HCP – 25,000 RED ≤ 8 min • RED: multiple dispatches (Delta and high end Charlie codes) GREEN 1 & 2* (~40%) • 317,000 NHS Direct Face to Face ≤ 20 min (Charlie & Bravo codes) CATEGORY • 3m website hits C GREEN 3 (~22%) Call Back CTA ≤ 10 min or Face to Face ≤ 30 min • 1m PCS Journeys (Alpha & Omega codes)

Designing ambulance into unscheduled care

Conditions for Change – Health Policy

Clinical Response Model CATEGORY RESPONSE MODE DEPLOYMENT MEASURES Blue lights Multiple Resources 65% within 8 minutes RED ≤ 8 minutes ( 60-70 calls per Ideal/Suitable day out of 1300) Blue lights Right clinician/resource Clinical Interventions AMBER Ideal/Suitable in a timely manner, based Patient Outcomes (65%) on clinical need. Hear and Treat Planned non-emergency Clinical Outcomes GREEN Normal Road Speed transport (ambulance/taxi): Patient Satisfaction (30%) Telephone advice / clinical assessment SIMPLE …… CLINICALLY FOCUSED…... PRUDENT …… SAFE

Process to achieve change in Wales • Clinical Modelling Workshops – Oct. 2014 • 16/1/15: Jeremy Hunt announces English pilot sites following letter from Keith Willett • 26/1/15: letter to Vaughan Gething from Welsh MDs • 29/1/15: response from Vaughan Gething asking WG officials to work with NHS Wales clinical leads • Extensive communication with staff & public, videos, FAQs and staff surgeries across Wales

Process • 24/4/15: CMO requests Case for Change revised with focus on patient experience & outcomes • June: presentations at Clinical Stakeholders including CMO/CNO, GPC Wales & Welsh CEM • 10/7/15: Letter from WAST MD to Vaughan Gething on behalf of MDs

29 July 15 changes announced in Senedd – it can be done! Go Live 1 October 2015 – 18 month pilot

Key Enabler: Digital Pen Technology for completing Patient Clinical Records

So what do we measure now? • “This striking result shows we must focus more on the care, compassion and continuity provided by our highly-skilled ambulance clinicians than simply measuring the worth of the service by the time it took an ambulance to respond to a 999 call”. • http://gov.wales/statistics-and-research/ambulance-services/?lang=en • http://www.wales.nhs.uk/easc/ambulance-quality-indicators

WAST Clinical Indicators 16

STROKE • Old System • Time from 999 call to ambulance or RRV arriving at address • Multiple dispatches – “perverse behaviours” • New System • Ideal or Suitable response • Clinical Indicator • Time to intervention? • Future System • Measures across USC system?

RED Performance

Lets look at December 15 v December 16. Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total 15 16 16 16 16 16 16 16 16 16 16 16 16 Total Verified Incidents 38,777 39,659 37,561 40,611 35,448 38,623 37,046 39,584 38,601 37,550 39,437 37,897 41,668 502,462 Conveyances to Hospital 18,900 18,911 17,498 18,765 17,266 18,405 17,278 18,308 17,813 17,282 18,496 17,421 18,442 234,785 • December 2016 - 41,668 incidents. • 2,891 more incidents than December 2015 • 458 less conveyances! • Resource shift of 3,349 cases…….

What have we learned? 40,000 90.0% 80.5% 79.5% 78.1% 75.3% 77.1% 78.9% 77.1% 77.9% 75.5% 75.8% 75.4% 74.6% 80.0% Number of Incidents Resulting in an Emergency Response 71.0% 35,000 70.0% 30,000 3,640 3,386 60.0% 3,944 3,690 4,066 4,442 25,000 4,021 3,832 3,577 3,793 4,139 4,096 3,332 50.0% Red 8 % 20,000 40.0% 23,970 15,000 23,548 22,802 22,381 22,362 22,139 21,868 21,931 21,878 21,546 20,971 30.0% 20,431 20,399 10,000 20.0% 5,000 10.0% 1,986 1,958 1,833 1,758 1,591 1,670 1,504 1,702 1,579 1,472 1,673 1,666 1,652 0 0.0% Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 RED Incidents* AMBER Incidents* GREEN Incidents* AW All Wales Red % in 8 mins

Amber Response (includes Amber 1)

Resolving ‘the Ambulance Problem’ - Collaboration • Local Health Boards • Police and Fire • AACE • Ministers • NHS Wales • Our Regulators • Our Commissioners • Board • Workforce • Trade Unions

“Indirect Benefits”

Frequent Callers Health Board Sep Oct Nov Dec Total Health Board Jun Jul Aug Sep Total Abertawe Bro Morgannwg 57 3 2 6 68 Abertawe Bro Morgannwg 82 15 13 9 119 Aneurin Bevan 51 16 18 20 105 92 87 30 20 229 Aneurin Bevan Betsi Cadwaladr 112 52 37 30 231 58 13 14 18 103 Betsi Cadwaladr Cardiff and Vale 76 25 12 11 124 Cardiff and Vale 77 21 8 10 116 Cwm Taf 59 12 5 13 89 Cwm Taf 21 11 9 7 48 Powys 4 16 3 1 24 All Wales 384 136 88 84 692 All Wales 305 135 63 61 564

Associated benefits • Staff Survey 2016 - best improvement (10% increase in engagement score) across NHS Wales • Decreasing sickness absence - lowest absence rates for years • Achievement of full establishment in Paramedic and EMT numbers (now over-recruiting) • Achieved ‘ routine monitoring ’ in 2016 - only NHS Wales organisation to be ‘de -escalated ’ • Partnership working with Trade Union colleagues • Reduction in vehicle allocations per incident. It is estimated that over 5,500 unnecessary allocations have been avoided since October 2015 • Sustainable savings delivered each year • Improvements in Frequent Callers, Clinical Desk, See & Treat • New ways of working: Specialist Paramedics in Community

NHS Confederation Wales: “The key enablers to outcomes based performance targets.” • When developing a performance management framework, the Welsh Government and other stakeholders should consider the key enablers that led to the implementation of the new Clinical Response Model (CRM) for the Welsh Ambulance Services NHS Trust (WAST). • The CRM pilot has moved the focus from a specific time target, other than where clinical evidence supports such a target, to improving outcomes and experience for patients through introducing a clinically appropriate response.

NHS Confederation Wales Review: The key enablers: The 10 enablers below have been identified from the CRM pilot as important factors to consider when developing new performance frameworks for the NHS. The enablers must be taken in their entirety because of the synergies between them. 1. Clinical evidence & leadership 6. Policy direction 2. Patient outcomes and 7. External stakeholder pathways support 3. Independent review 8. The operating environment 4. Staff support 9. External messages 5. Political Support 10. Audit and benchmarking

Clinical evidence and leadership: • Gaining support and advice from clinicians when developing a new performance management framework is critical. • Working with Medical Directors across the NHS and gaining support from senior clinicians within Government to develop new targets is essential to ensure that patient pathways and clinical outcomes are considered.

External messages: • It is key that NHS leaders engage with the media and provide consistent messages around why the changes are required and evidence the benefits to patients. • As well as the media, it is important to keep Assembly Members informed about the process and highlight the evidence of how it will improve patient outcomes.

Audit and benchmarking: • Once the pilot has been developed, it is critical that a clear audit of the process is developed and information released publicly. • As part of the audit, it is important to consider all LHBs’ performance so that we can benchmark to drive up consistency and improvements across Wales.

Conclusion • One of the key barriers to shifting from specific time targets to a clinical indicator patient outcome-focused model, considering the NICE guidance, is that the different stages of the patient pathway are presently not recorded. • We will, therefore, have to introduce, collate and record the new clinical indicators and measures on the NHS data system. • The evidence available demonstrates outcome-based targets are able to be introduced into the NHS and that these targets can drive up performance and enhance patient safety and experience.