NHS County Durham & Darlington

Ambulance evaluation research:Key insights (March 2013)

June 2013Presented by Joanne Loughlin-Ridley

Introduction

Explain was commissioned by NHS County Durham & Darlington in 2012 to deliver a comprehensive research programme that would independently evaluate the evidence based model of ambulance provision that was operating in the Durham Dales at that time.

Public

• On-street survey with 366 local residents

Patients

• In-depth telephone interviews with 13 patients

Professionals

• In-depth telephone interviews with 21 relevant professionals

216 Teesdale, 150 Weardale

Random selection

Mix of demographic

profiles

8 Teesdale, 5 Weardale

Opt-in sample

12 emergency care / 3

primary care

14 Teesdale, 12 Weardale

Nominated sample

Included operational

and strategic roles

Fieldwork was completed between mid-January and mid-March 2013, with insight delivered at the end of March 2013.

Model

Below is an outline of the model of provision in the Dales which was central to the research:

WeardaleThere is one 24 hour ambulance crewed by two Paramedics based at St John’s Chapel. There is one rapid response car crewed by one Paramedic seven days a week 07.00-19.00 working from St John’s Chapel. The crews work closely with GPs in both St John’s Chapel and Stanhope, and are able to carry out a number of tasks.

TeesdaleThere is one 24 hour ambulance crewed by two Paramedics based in Barnard Castle.There is one ambulance crewed by two Paramedics seven days a week 08.00-20.00 working from Middleton-in-Teesdale.The Paramedics are available to work with the GP practice in Middleton, and are able to carry out a number of tasks.

In both areas, the tasks that the ambulance service crew can assist GPs with is the same: Completing discharge reviews Administering flu vaccinations Taking urgent bloods Reviewing COPD patients Completing a ‘well person review’ for patients over 80 who have not had contact with their GP for some time to review

their blood pressure, pulse, oxygen levels and general healthThey also respond to GP home visits so that the GPs can stay in the surgery and see patients with appointments uninterrupted.

In both areas, the ambulance service crew can also provide support to local community hospitals by taking patient bloods for example, and setting up IVs (drips).

Key insight: satisfaction

High levels of satisfaction found from patients of the ambulance service, particularly in relation to the crew being caring and compassionate, helpful and reassuring

Quick and efficient

Professional and helpful

Familiar faces

Calming and chatty

Reassuranceand

comfort

Overall (146-147)

Weardale (62-63)

Teesdale (83-84)

How long it took to be seen 86% 82% 89%How long it took to travel to hospital 80% 78% 82%How clean the response vehicle was 85% 84% 86%How compassionate and caring the crew were 93% 92% 94%How helpful the crew were 94% 94% 94%How well they kept you/your family or friends informed 91% 89% 92%How well the care matched your needs 90% 89% 91%The overall quality of care they delivered to you 89% 87% 91%

Patients that discussed positive experiences identified key contributors:

Key insight: reputation

Identification that the ambulance service is very valued by the wider local community also, a strong and positive reputation found

Patients discussed how valued the local ambulance crew are in the Dales:

“Everybody is positive about them...round here there’s only praise as far as I know for the ambulance service here. Oh God, I couldn’t do without them. Honestly, we could

not do without them. This would be disastrous, where we are in Romaldkirk. You need a fast response to here. And there’s some quite elderly people in the village, so you

would rely on them” (Teesdale – stomach pains)

Yes No

15%

86%

20%

80%

11%

89%

Have you heard anything negative about the local ambulance service in the last 12 months?

Overall (366) Weardale (150) Teesdale (216)

The model of provision was detailed to patients and the public and was very well received, particularly for the benefits of local GPs, with no consistent themes for improvement found

Key insight: reviewing the model

Good use of the crews

time

GPs are busy and

will find this helpful

Crew are / become familiar

faces

Could prevent

admissions

Support is great,

especially for older people

Patients that discussed positive experiences identified key contributors:

Positive Indifferent Negative

78%

15%10%

85%

8% 8%

73%

19%

8%

How do you view the Paramedics supporting the local GPs?

Overall (364) Weardale (143) Teesdale (221)

Key insight: strengths of the model

Many strengths of the service model were identified by stakeholders, particularly the primary care role of paramedics in local communities and the prevention of (re)admissions

Social care for those

vulnerable

Builds familiarity with local

people

Good use of time and resource

Being based in area to

respond more quickly

Improved patient

outcomes with two

paramedics per vehicle

High caliber paramedics

Local knowledge

allows a quicker

response

Prevents admissions and re-admissions to hospital

A model that is being held up nationally as 'good practice'

Key insight: weaknesses of the model

The majority of stakeholders discussed weaknesses of the current model, it not working in practice due to ongoing challenges such as the impact of the 111 system, delayed handovers of patients at hospitals, and ‘critical escalation’ leaving the Dales without cover

Reduction of wider resource in North East

Critical escalation becoming more frequent

Delays in handover of patients at hospitals

Once out of area, must respond if closest to a call

Impact of the 111 system not working as planned

Reduces opportunities for community work

Perception is that the service model is not working in

practice

Key insight: paralleled perspectives

Feedback from the ambulance control staff stood out as distinctive from other stakeholder roles, perceiving of the service model as ‘above and beyond requirements’

Control staff did not echo the concerns of other professionals about the model not delivering sufficient coverage in the Dales, holding a paralleled perspective that the model exceeded requirements and could be reduced in the future:

“People’s lives will be put in danger, and I know that's quite a strong thing to say, in fact I’ll say it

even stronger, people will die if we don't have a 24-hour proper crewing system here in the Dale. We are

so remote, we have an aged population, and definitive care for a number of different things, for

example, heart attacks, and trauma, are a long way away...if we don't have 24-hour cover, and someone

has to come into the Dale to do that, then that's a long way to go” (Paramedic)

Protect the provisionReduce the provision

“I don't think it requires any more than any other ambulance, one paramedic and one other...

they've got four vehicles operating, during the day, and two vehicles operating through the

night, and for the demand they've been treated very generously,… you could probably take one vehicle out of that equation… I don’t have this much cover in Durham city centre… they are

getting above and beyond… It’ll be more efficient by not having the Middleton vehicle at all without

hurting the service, I could use that vehicle somewhere else, much more efficiently”

(Ambulance control staff)

Key insight: improvements

The majority of stakeholders discussed improvement mainly in terms of ensuring the service model was being delivered to provide ‘true’ 24 hour cover in the Dales

In order to provide ‘true’ 24 hour cover in the Dales a number of improvements were noted..

Investigate causes of critical escalation across NEAS patch which takes / keeps ambulances out of the Dales

Improve 111 system

Improve handover on admissions to

A&E

Allow admissions to community

hospitals nearby

Cover across NEAS to improve

Consideration of ring fencing

Be transparent about performance so areas for improvement are evidenced

and clear for all involved

A number of other areas were discussed also:- Importance of 2 paramedics per vehicle due to the distance from hospitals- Training required to deliver valuable primary care to the Dales communities to tackle (re)admissions - 4x4 vehicle being needed all year long in Weardale- Ambulance station at St John’s Chapel being in need of attention / review- Retention of paramedics in the Dales and wider NEAS patch

Strained relationships and communication were found between stakeholder groups, and a call for increased transparency as to performance rates was evidenced as a way forward

Key insight: communication

Paramedics

Information is not disseminated on

performance

No opportunities available at operational

level to feed back

Community representatives

Unresponsive to queries / concerns

highlighted

Actions not followed through as agreed

Seen as 'opposition' not as partners

GP

Crew seem disengaged and morale can appear

low in light of this

Lack of information / justification for

performance levels

Evidence of ongoing frustrations were found in regards to some of the professionals relationship and communication with the NHS and with NEAS specifically:

By its nature of exploration research can often unearth many questions alongside answers and so a number of areas for further exploration have been recommended

Key insight: challenge

Based on the current feedback, consider and explore the feasibility of ‘smarter working’ across services, to minimise the ‘strain’ on the ambulance service that impacts on provision and

performance in the Dales

Tackle the causes of delay in hospitals when admitting

patients

Alternative care pathways for patients in need of social

care

Ensuring 111 calls are handled correctly with appropriate responses

delivered

Clear guidance for the public on ‘out of hours

services’ to reduce misuse

Comprehensive and independent analysis of performance data of the ambulance service in the Dales and across the NEAS patch is advised, including an assessment of the paramedics role in supporting

GPs and community hospitals

Need to verify the strong concerns of professionals

Due to strained relationships and mistrust amongst professionals this is

advised to be independent

Transparency with the outcomes is key to building trust and relationships