Have you noticed that everywhere you look in the NHS nowadays everything is “transforming” it is the latest overused buzz word…. What does it really mean? It isn’t some magical process that comes along and changes everything overnight then goes away again… our experience of real redesign and improvement of complex interdependent services is much more about a series small steps leading to an ambitious goal…
Take emergency ambulances… We had a problem. We are a large rural area and our 8 minute response times for Red 1and2s ( emergencies) languished around the mid 50% for years and years. The only answer seemed to be investment in more ambulances but most of the time they would be doing nothing…. There had to be another way..
So working with our ambulance service we looked at a series of other measures… some really simple.
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moving where ambulances stand and wait… for example :from the station up a hill above the only set of lights in town to the local co-op on the other side of the lights.. an average of a minute saved on trips up the dale…
A formal arrangement with local practices to take over responsibility for cases where the paramedics don’t feel a 999 call patient needs to be taken to A&E but could be given more appropriate care by their general practice…
Paramedics working in primary care.. developing skills.. providing home visits..the next stage of which is a paramedic working out of our local A&E….
Where has this got us.. well this month our Red1/2 response was up to 72% AMAZING!
The next step is to tackle GP urgents…these are calls for ambulances GPs make when they have been out to see a patient at home and decide they need to be admitted to hospital.
GPs usually visit patients who request visit after morning surgery is finished . Some of those will be sent into hospital for tests , investigations and treatment. We discussed with our GPs whether they could arrange to visit patients earlier in the day so patients who needed to be admitted could be sent in earlier to allow the hospital to investigate and treat them on the day they arrive and possibly get home the same day. The GPs felt the patient would get a better service and would be less likely to be admitted, if they were seen by their own GP who knew them and their case than from a visiting duty doctor from the practice
So if they couldn’t be seen sooner, we needed to get them into hospital quicker. If they are very unstable then obviously they need to use the 999 system but for those who are unwell but don’t require emergency transport an ambulance is booked to take them into hospital in a maximum of 4 hours. Sometimes, if there is a lot of emergency activity going on in the area the service may phone back and ask for an extension to that. So it can take hours for patients to get into hospital. They are at home with their families worrying, expecting any moment that the ambulance will come. The hospital is waiting for them to come… if the hospital is a long way away it can take up to 6 hours for them to actually get there…Although some patients are transported by non emergency ambulances much of the time the system relies on the 999 ambulances to do the GP urgent calls. This then reduces the ambulances available for 999 calls.
We wanted to change this. So ,with some of our system resilience money we are running a proof of concept pilot partnering with an organisation called 365response to provide an alternative to our usual ambulance service. They are a public/private partnership who have done all the ground work to develop a safe ,high quality service specification and develop the market. We then did a mini tendering exercise with providers already preselected by them. The new service is manned by emergency care assistants who have more skills than standard PTS drivers but less than paramedics
Our GP practices have a new decision tree which allows them to select the appropriate mode of transport( Paramedic ambulance/ new service ambulance/ own transport) for the patient based on their clinical condition. The new service has a target time of 2 hours from call to arrival at scene.
In the first week: 11 GP Urgent patients were conveyed through the new transport pathway- all safely and with excellent response times and total call cycle times from booking to the patient's arrival at their care destination in less than 2hrs.
Every time a patient is referred to the new service this generates at least 2 hours of additional A&E 999 ambulance resource back into the emergency service and thereby available to respond to our 999 emergency calls. Therefore last week around 22 hours of additional emergency ambulance time was available to YAS across our patch. The medical teams at the hospital have already noticed that paitents are arriving earlier giving them the chance to instigate treatment sooner and hopefully get them home sooner. A win win!
It is early days but it looks really good.
