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

• 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

Our ‘Burning Platform’ - 2013 Operating Context

The Problem: Contacts 2013/14

• 999 – 420,000 calls
• 40% or 166,000 RED 1&2
• 86,000 HCP – 25,000 RED
• RED: multiple dispatches
• 317,000 NHS Direct
• 3m website hits
• 1m PCS Journeys

CALL TYPE CATEGORY & CODE (MPDS)

CATEGORY A RED 1 (~3%)

≤ 8 min

(Echo and high end Delta codes)

RED 2 (~35%)

≤ 8 min

(Delta and high end Charlie codes)

CATEGORY C GREEN 1 & 2*(~40%)

Face to Face ≤ 20 min

(Charlie & Bravo codes)

GREEN 3 (~22%)

Call Back CTA ≤ 10 min or Face to Face ≤ 30 min

(Alpha & Omega codes)

Designing ambulance into unscheduled care

Conditions for Change – Health Policy

Clinical Response Model

CATEGORY RESPONSE MODE DEPLOYMENT MEASURES

RED

( 60-70 calls per day out of 1300)

Blue lights ≤ 8 minutes Ideal/Suitable Multiple Resources 65% within 8 minutes

AMBER

(65%) Blue lights Ideal/Suitable Right clinician/resource in a timely manner, based

• n clinical need.

Clinical Interventions Patient Outcomes

GREEN

(30%)

Hear and Treat Normal Road Speed Planned non-emergency transport (ambulance/taxi): Telephone advice / clinical assessment Clinical Outcomes Patient Satisfaction

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 15 Jan 16 Feb 16 Mar 16 Apr 16 May 16 Jun 16 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Total 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?

1,591 1,670 1,504 1,702 1,579 1,472 1,673 1,666 1,986 1,958 1,652 1,833 1,758 20,399 22,139 20,971 22,362 21,931 21,546 22,802 21,878 23,970 23,548 20,431 22,381 21,868 4,096 4,442 4,139 4,066 4,021 3,793 3,944 3,832 3,640 3,386 3,332 3,690 3,577

71.0% 75.5% 77.1% 75.3% 78.1% 79.5% 77.1% 78.9% 75.8% 75.4% 74.6% 77.9% 80.5%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000 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 8 % Number of Incidents Resulting in an Emergency Response RED Incidents* AMBER Incidents* GREEN Incidents* AW All Wales Red % in 8 mins

Amber Response (includes Amber 1)

Resolving ‘the Ambulance Problem’ - Collaboration

• Ministers
• NHS Wales
• Our Regulators
• Our Commissioners
• Local Health Boards
• Police and Fire
• AACE
• Board
• Workforce
• Trade Unions

“Indirect Benefits”

Frequent Callers

Health Board Jun Jul Aug Sep Total Abertawe Bro Morgannwg 82 15 13 9 119 Aneurin Bevan 51 16 18 20 105 Betsi Cadwaladr 112 52 37 30 231 Cardiff and Vale 76 25 12 11 124 Cwm Taf 59 12 5 13 89 Powys 4 16 3 1 24 All Wales 384 136 88 84 692 Health Board Sep Oct Nov Dec Total Abertawe Bro Morgannwg

57 3 2 6 68

Aneurin Bevan

92 87 30 20 229

Betsi Cadwaladr

58 13 14 18 103

Cardiff and Vale

77 21 8 10 116

Cwm Taf

21 11 9 7 48

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

• utcomes 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
• 2. Patient outcomes and

pathways

• 3. Independent review
• 4. Staff support
• 5. Political Support
• 6. Policy direction
• 7. External stakeholder

support

• 8. The operating environment
• 9. External messages
• 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.

PACEC & Medical Care Research Unit, University of Sheffield, Review

• Evaluation Objectives:

– Clinical Indicators/Outcomes – to demonstrate the effect of the removal of time-based response standards on clinical performance – Value for Money – establish the cost effectiveness of ambulance services – Patient Experience – impact of new model on patient satisfaction and welfare – Staff perceptions – WAST and Health Board

PACEC & Medical Care Research Unit, University of Sheffield, Review

• Findings:

– Clear and universal acknowledgement from WAST and external stakeholders that new CRM ‘appropriate and right thing to do’ – No new risks to patient safety introduced by CRM – Without CRM likely that there would have been significant risk for patients, particularly

• ver winter

– No serious safety concerns – Positive impact on performance – response time reliability increased substantially – Fewer resources used per incident, regardless of categorisation – Direct costs reduced – Stroke consistent and STEMI improving – Much more clinically focussed service – WAST much more visible to wider health system and a central player rather than passive recipient

Culture & External Recognition

The things we would do differently are….

– Re-profile our resourcing prior to model change – Undertake a Demand & Capacity review first – Continuously check that all stakeholders, internally and externally, and partners remain on the journey with us, updated and involved at every stage and review – Think long and hard about our approach to rural areas and areas with low population bases – Ensure all conversations are clinically led – especially in relation to Red to Amber – E-PCR

if we were doing it again…

Transforming Ambulance Services in Wales

Clear Accountability Establishment of EASC Collaborative Commissioning CAREMORE/Five Step Model New Clinical Response Model Ambulance Quality Indicators Creation of CASC Role

System Change

WAST Organisational Transformation Improved Outcomes

Transforming Ambulance Services in Wales System Change

New Board New Leadership Improved Governance Community/Stakeholder Focus Clinical Modernisation Workforce Modernisation Staff Re-engagement NEPTS WAST Organisational Transformation Improved Outcomes

Transforming Ambulance Services in Wales System Change

Improving Quality Improving Performance Financial Balance Improving Media Profile Renewed Credibility De-escalation BUT… Still Early Days Much More To Do Need Consistency

WAST Organisational Transformation Improved Outcomes

Welsh Ambulance Service Transformation Journey

1998 Formation

• f WAST

2004- 2008 Medical Assessment Model 2011 Working Together for Success 2013 McLelland Review

2014 - 2017 Clinical Transformation

Transport Organisation (‘Scoop and Drop’) Clinically Focused Emergency Service Embedded in the Unscheduled Care System

The first responsibility of a leader is to define reality. The last is to say thank you. In between, the leader is a servant. (Max De Pree)